HEALTH
NCJfT TO CIRCULATE
HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND AT
BALTIMORE
not to
Digitized by the Internet Archive
in 2016
https://archive.org/details/journalofarkansa9311arka
HEALTH SCIINCIS LIIRARY
UNIVERSITY OF MARYLANB AT
BALTIMORE
Journal
OF THE Arkansas
MEDICAL SOCIETY
June 1996
Volume 93 Number 1
Arkansas Medicat Soc^ty President,
John Crenshaw, M.D.,
and his wife Donna Crenshaw
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE
David Wroten
PRESIDENT
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
Obstetrics/Gynecology
Internal Medicine
Surgery
Family Practice
UAMS
Volume 93 Number 1 June 1996
CONTENTS
FEATURES
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information; Contact Tina G. Wade, The
Journal of the Arkansas Medical Society, P.O. Box 5776,
Little Rock, AR 72215-5776; (501) 224-8967.
Postmaster; Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 5776, Little
Rock, Arkansas 72215-5776.
Subscription rate; $30.00 aimually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
Press, Inc., Fulton, Missouri 65251. Second class
postage is paid at Little Rock, Arkansas, and at addi-
tional mailing offices.
Articles and advertisements published in The Journal
are for the interest of its readers and do not represent
the official position or endorsement of The Journal or the
Arkansas Medical Society. The Journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1996 by the Arkansas Medical Society.
5 Medicine in the News
Health Care Access Foundation Update
IVlanaged Care News & Information
AMA Calls for Divestment of all Tobacco Stocks & Mutual Funds
AMS Council Take Action regarding Divestment of Tobacco Related
Stocks, Bonds & Funds
15 Inaugural Address
John Crenshaw, M.D.
18 1996 Convention Keynote Speakers
20 House of Delegates Composition
22 Proceedings of the 120th Annual Session
22 First Session
23 Final Session
24 1996-1997 Officers
26 Reference Committee #1
27 Reference Committee #2
28 Report of the Council
30
Farewell Address
James Armstrong, M.D.
33
AMS Alliance Annual Session Report & Presidential Address
36
Fifty Year Club
37
1996 AMS Shuffield Award
39
1996 Grand Prize Winners
40
1996 Annual Session Sponsors
42
1996 Annual Session Exhibitors
45
In Memoriam
DEPARTMENTS
11
AMS Newsmakers
47
Cardiology Commentary & Update
49
State Health Watch
52
Arkansas HIV/AIDS Report
54
New Members
55
Radiological Case of the Month
57
Things to Come
59
Keeping Up
Cover photograph taken by Franklin Washburn Photography in Little Rock. Annual Session
photographs taken by Joel Schmidt of Joel's Photography in Little Rock. Various photographs taken
by AMS staff members Tina Wade and Laura Harrison. Photographs of Golf Tournament taken by
David Wroten, AMS Assistant Executive Vice President.
Managed Care:
Global or Local?
Arkansas Managed Care Organization Serves
Locai Partnerships Providing Community Care.
The world of managed care is expanding, often
ignoring the benefits of local partnerships among
employers, employees, doctors and hospitals.
The global outlook suggests restricted health care
delivered only by those providers who agree to
lower rates in return for guaranteed patients.
Arkansas Managed Care Organization (AMCO)
believes there is a better way to reduce cost and
ensure quality care.
Health Care's Better Way
Formed as a PPO in 1994, AMCO has assembled
a strong network of 1,700 local doctors and 38
local hospitals covering 75% of Arkansas. Our
philosophy for quality care relies on these stable
local partnerships - run by local boards made up
of doctors, hospitals and employers -- to ensure
access and affordability. And AMCO can provide
coverage to Arkansas’ multi-state employers
through our national network.
Physician's Practice
Where Patients Live
AMCO’s local partnerships mean physicians can
still practice where patients live, while
experiencing practice growth through local
employer contracts. The link between managed
care and community care combines the benefits
of a statewide network with the security and
convenience of hometown medical attention.
For information on local partnerships for
community care, call AMCO at 1-800-278-8470.
#10 Corporate Hill Drive • Suite 200 • Little Rock, Arkansas 72205 • (501) 225-8470/FAX (501) 225-7954 • 1-800-278-8470
AMCO is affiliated with Arkansas Medical Society Management Company.
Medicine in the News
Health Care Access Foundation
As of May 1, 1996, the Arkansas Health Care Ac-
cess Foundation has provided free medical service to
10,942 medically indigent persons, received 20,012 ap-
plications and enrolled 39,486 persons. This program
has 1,716 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
Managed Care News and Information
Medical-malpractice Insurance Rate Increases Due to
Managed Care?
According to a recent news article, a Texas medi-
cal-malpractice insurer recently sought a 22.9% rate
increase citing growing losses from rising misdiagnoses
among physicians in HMOs and other managed-care
practices.
The article stated that by using primary-care phy-
sicians as "gatekeepers" to more expensive specialties,
managed care is supposed to cut costs. "If the idea is
to treat patients as cheaply as possible and refer as
few as possible, there obviously are going to be some
patients who should have been referred earlier," an
insurance company executive was quoted as saying.
"So there's an increased liability for physicians," he added.
The medical-malpractice insurer argued in its rate
request that "gatekeepers" are costing it money and
are a major factor behind its need to raise malpractice
rates. A company executive indicated that they are
not attributing the rate increase entirely to that trend
but that they have identified increased losses due to
misdiagnoses. He also said that managed care puts
greater responsibility on primary-care physicians to do more.
In the article, a lobbyist for the Texas Medical As-
sociation was quoted as saying, "You're going from
one extreme, where there was perhaps too much care
and too much defensive medicine, to a point where
there may not be enough care and not enough defen-
sive medicine. It's a difficult balance."
Although the 22.9% rate increase request was rejected
by the Texas Department of Insurance, it signals a
warning that should be watched closely in the future.
Gatekeeper Liability: Ten Topics of Concern
Reprinted with permission from St. Paul Fire and
Marine Insurance Company from its 1995 Year-end
Physicians and Surgeons Update
The ever-increasing penetration of managed care
throughout the United States has given rise to new
and evolving concerns for physicians acting as
"gatekeepers."
"Gatekeepers" are primary care physicians who
serve as the patient's initial contact, and are then re-
sponsible for providing care as appropriate, and coor-
dinating any needed consultations or referrals.
"Primary care physicians as gatekeepers are doing
less primary care and more coordination of care and
administrative work," noted Paul R. Frisch, J.D.,
C.A.E., director, Medical-Legal Affairs, Oregon Medi-
cal Association. "That coordination, as well as other
gatekeeper responsibilities, raise a number of highly
interesting legal and ethical issues for gatekeepers,"
Frisch said. "I'm neither an advocate nor a detractor
of the managed care concept," he added. "But from
the physician's perspective, it can at times feel like the
ground is shifting beneath you in the managed care
environment."
Ten legal and ethical concerns for gatekeepers, with
commentary on each from Frisch, are:
1. ) Joint responsibility as manager of care AND steward of
resources allotted for care.
"How does the primary care physician wear both
hats? This is less of a liability concern - though it can
develop into one - than an issue related to the profes-
sional role and performance of doctors. It also hinges
on expectations. The expectations a managed care plan
has of the gatekeeper might not be in line with the
expectations of the patient. The patient, in fact, is prob-
ably unaware of any expectations other than that the
gatekeeper will be his or her advocate. The patient
may not even know the physician is serving as a
gatekeeper.
"In a fee-for-service arrangement, the physician's
concerns were more focused on individual patients.
Today, the gatekeeper's concerns extend to an entire
population of patients, with a finite amount of dollars
to fund the care they receive. This can cause some
tension for physicians who tend to identify more with
individual care decisions."
2. ) Liability exposure related to "wellness" issues.
"The managed care emphasis on wellness raises
liability issues for the gatekeeper. The physician can
in a sense get caught up in the advertising and pro-
motional efforts of the managed care group. The ad-
vertising might not only tout access to the 'physician
of your choice,' but all kinds of wellness services to
keep you healthy. Look at the debate over
mammograms. When is one appropriate? Individual
doctors, the government and managed care firms may
all have different answers. If the plan offers
mammograms as a benefit of its 'wellness program,'
Volume 93, Number 1 - June 1996
5
failure to provide one poses a liability risk. If the test
is read by someone who is not as qualified as the per-
son who would read it under a fee-for-service arrange-
ment, that might pose a liability risk. If we don't prac-
tice 'wellness medicine' or don't do it right, it can cre-
ate a liability exposure for the gatekeeper above and
beyond the standard of care issues, because these ben-
efits were advertised and promoted very specifically
by the plan."
3. ) Limitations on use of clinical resources.
"The local standard of care and the plan benefits
don't have to be the same, and frequently they are
not. If the plan does not pay for certain tests or proce-
dures or prefers one over another, that may be at odds
with the local standard of care. Groups of physicians
may say it is the standard of care in this community to
treat a given condition with a certain test or proce-
dure. But if the managed care plan does not provide
payment for that course of action, the physician is
caught between doing what the contract allows and
what the standard of care in the community might be.
And if the physician provides care that differs from
the plan benefits, it may at a minimum expose the
physician to criticism regarding costs."
4. ) Financial incentives to reduce cost of care.
"There are three financial incentives under man-
aged care designed to encourage physicians to reduce
costs; bonuses, risk pools/withholds and penalties. Its
important to note these incentives are not meant to
encourage doctors to provide 'less care.' But some of
the contract wording can be inflammatory.
"The appeal can be great: 'Doctor, we can pay you
money over and above what you would earn in a
fee-for-service arrangement if you are mindful of cost
concerns. The American Medical Association's poli-
cies encourage organizations that use bonuses, risk
pools and penalties to view the patient population as
a whole and not to design systems that penalize both
patients and gatekeepers for individual patient care
decisions."
5. ) Financial penalty for exceeding quotas.
"Managed care plans instruct gatekeepers to 'Plan
not to do more than X number of tests or procedures
of a given type. Don't be an overutilizer.' These num-
bers or quotas might be based on some ideal of what
the average physician in the community is doing.
"The pressure to conform might be from your
peers. They might question why you ordered that test
or prescribed that drug. If you are thinking about the
cost of care for an entire population of patients based
on a specific budget for that care and penalties for ex-
ceeding that budget, you're going to be more conscious
about using more expensive drugs or procedures. But
6
the gatekeeper always must be mindful of making
medical care decisions, not solely financial decisions."
6. ) Business responsibilities to/interactions with
non-physicians.
"The bean counter meets the physician. What is
the gatekeeper to think when someone without the
same kind of clinical and professional interests and
background is evaluating him or her and making rec-
ommendations? Aside from the issues related to per-
sonal interaction, the gatekeeper has to consider
whether his interests and the interest of the patient
are at odds in any way with these contractual reviews,
which are more focused on dollars and cents than clini-
cal outcomes."
7. ) Non-physician access to confidential patient information.
"Does the patient who enrolls in a given health
plan know that the plan reserves the right to review
patient records... and does so frequently?
"The hallmark of the physician-patient relation-
ship is trust. Information relevant to the patient's health
should be discussed freely between the gatekeeper and
the patient and placed in the medical record. It's not
always in the patient's best interest if this information
is made known to others, especially non-physicians.
There is no adequate way to audit patient records with-
out some patient identifier being included. Some man-
aged care plans want to assess the physician's perfor-
mance and interaction with patients. And they ask to
review patient records to do that. It's clearly inappro-
priate, but it's done all the time."
8. ) Restrictions on referrals, or profile-based referrals.
"The profile-based referral focuses the gatekeeper's
attention on specialists whose charges fall within the
acceptable cost parameters of the managed care group
or their own individual practice association (IP A). Or
the restriction on referrals may be based on an ap-
proved panel of specialists. If your dollars are on the
line as a gatekeeper participating in the financial risk
of care there may be a tendency to refer to those spe-
cialists who are most cost-conscious. But the liability
risk for the gatekeeper is that he or she is making that
referral based on his or her financial benefit, instead
of in the best interest of the patient.
"Also, if the approved panel of specialists avail-
able for referral is too restricted, the gatekeeper could
be held vicariously liable for the care provided by that
specialist, because the patient's choice of a specialist
provider was so unduly limited."
9. ) Contractual assumption of financial and medical liability risk.
"The key to the contractual assumption of finan-
cial risk is that most plans do not allow physicians to
balance-bill patients. Patients might be responsible for
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Top Ten Allegations by Frequency
1994
Rank
1995
Rank
Allegation
Number
of Claims
Average
Cost
1
1
Surgery /Postoperative Complications
1,019
$ 73,300
2
2
Failure to Diagnose/Cancer
441
$123,100
3
3
Surgery /Inadvertent Act
362
$ 91,000
4
4
Improper Treatment/Birth-Related
346
$132,800
5
5
Failure to Diagnose/Fracture-Dislocation
205
$ 55,600
6
6
Improper Treatment/Drug Side Effect
194
$ 72,700
7
7
Failure to Diagnose/ Abdominal Problems
174
$ 71,300
8
Failure to Diagnose/Circulatory Problems
168
$111,000
8
9
Improper Treatment/Infection
164
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it- if*
10
Failure to Diagnose/Infection
161
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***Did not appear in 1994 Allegations Review.
Reprinted with permission from St. Paul Fire and Marine Insurance Company
from its 1995 Year-end Physicians and Surgeons Update
a co-payment or a de-
ducible, but they can-
not be billed for costs
over and above what
the plan pays the phy-
sician for care. In a
worst case scenario,
the plan may deny
payment altogether,
and the physician is
contractually barred
from attempting to re-
coup any of his or her
costs.
"The other piece of
this risk puzzle is the
medical liability risk.
Let's suppose a patient
has a certain medical
condition that falls un-
der the plan's utiliza-
tion review policy. The
patient could probably benefit from a course of treat-
ment not covered by the plan. The physician explains
the pros and cons of both treatment options and the
patient chooses the option covered by the plan. The
patient suffers an adverse result.
While the issue is currently the subject of spirited
debate, managed care entities today may be held harm-
less from any liability in this type of lawsuit because
of the ERISA (Employee Retirement Income Security
Act) statute. Physicians are sometimes amazed when
they learn this. They ask me, 'You mean the managed
care plan is not responsible for its actions?' And I have
to tell them 'No, doctor, you are."
10.) "Gag" provisions.
"Most physicians and patients would agree that
physicians must adhere to an ethical and professional
standard of care that says they must be an advocate
for the patient's best interests. If that is the case, then
a gatekeeper must be assertive about issues he or she
has with managed care plan policies. The gatekeeper
should fight for the patient, use the mechanisms avail-
able to him or her to pursue change in the plan and
above all, tell the patient about these concerns.
"But, if you happen to be an attorney for the man-
aged care plan, it might make a great deal of sense to
try to limit what the gatekeeper can say about the plan.
The attorney might not see this as a First Amendment
issue, but as a common sense business issue. Their
view is, 'Thou shalt not cast the plan in a bad light.'
"So, what are known as 'gag' provisions have
sprung up in managed care contracts with physicians.
They prevent the physician from communicating to
the patient negative views about the plan, its policies
8
and structure. To the lawyer, it doesn't matter that the
physician has an ethical duty to the patient. The
lawyer's job is to keep the patients enrolled and to
maintain the image of the plan. 'Gag' provisions, no
matter how horrendous they may seem to the
gatekeeper, help do that. But they clearly put the
gatekeeper in an ethical bind."
AMA Calls for Divestment of all Tobacco
Stocks and Mutual Funds
Physicians group publishes list of 13 stocks and 1,474
mutual funds to avoid.
The AMA recently called on investors to divest of
13 stocks and 1,474 mutual funds that manufacture
tobacco or invest in tobacco companies calling tobacco
a "ruinous and enslaving product that has brought
misery, disease, anguish and death."
The 13 stocks are publicly traded companies that
manufacture and distribute tobacco products. The 1,474
mutual funds singled out by the AMA reported hold-
ings of tobacco stocks or bonds, according to indepen-
dent research conducted for the AMA.
Physician Recommendations
"All physicians, health professionals, public health
advocates, medical institutions, hospitals and all people
interested in the health and welfare of our children
should review their investments and divest of tobacco,"
said Randolph Smoak, Jr., M.D., secretary-treasurer
of the AMA and a South Carolinian surgeon.
Specifically the AMA recommended;
1.) All institutions and individuals review their assets
and divest of any shares in the listed stocks and funds,
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
2.) and/or inform their mutual fund
managers that tobacco holdings should
be sold and are not acceptable invest-
ments.
The physician organization
plans to update and publish the list
annually in its publications. In ad-
dition, the AMA has written to all
7,000 mutual funds traded in the
U.S. asking them to join a "Coali-
tion of Tobacco-Free Investments" by
pledging not to invest in tobacco in
the future.
Research conducted independently
The list was compiled by the In-
vestor Responsibility Research
Group (IRRC) a not-for-profit, inde-
pendent research firm, based in
Washington, D.C., that has tracked
tobacco and public health issues.
IRRC identified mutual funds with
investments in tobacco based on
analysis of Morningstar Inc., data.
Morningstar surveys mutual funds
about their equity and debt holdings,
and periodically analyzes N-SAR
(semi-annual report) forms that mu-
tual funds must file under U.S. Se-
curities law.
"How can we allow any of our hard-earned money
to support any portion of the tobacco industry?" asked
Smoak. "When tobacco is no longer profitable, when
children no longer are exposed or succumb to cartoon
tobacco enticements and when this country's inves-
tors refuse to take dividends from an industry whose
product causes suffering and addiction, then these
American companies will join the
realm of responsible corporate citi-
zens."
The AMA also renewed its sup-
port for the proposed FDA regula-
tions on tobacco and called on the
industry "to accept the FDA regula-
tions in their entirety and follow
these regulations in spirit and in
law" to solve their current image, legal
and regulatory problems.
Past Divestments
AMA's call for divestment of to-
bacco stocks in mutual funds follows
its decision in 1986 to divest tobacco
stocks in AMA's portfolio. Other
public health organizations divest-
ing during the 1980s include the
American Heart Association, Ameri-
can Lung Association and Ameri-
can Cancer Society. Since 1990, sev-
eral leading universities with medi-
cal schools have responded to
AMA's call for divestment of tobacco
holdings including Harvard, Johns
Hopkins, Wayne State and City Uni-
versity of New York.
A complete listing of the 13
stocks and the 1,474 mutual funds
with tobacco holdings is available by calling AMA at
202-789-7447. Dr. Smoak's remarks and the AMA/IRRC
report listing of the 1,474 mutual funds with tobacco
holdings are available on the AMA's Homepage at
http://www.ama-assn.org in the What's New Section.
- Information provided by the AMA FED-NET, April 24,
1996.
AMS Council Take Action
Regarding Divestment of
Tobacco Related Stocks,
Bonds & Funds
During the Annual Session
Council meetings May 2-4, Dr.
William Jones discussed the
AMA's recent announcement
concerning the divestment of all
tobacco related stocks, bonds
and mutual funds. Upon mo-
tion, the Council voted for the
Budget Committee to undertake
a comprehensive study of invest-
ment portfolios of the Arkansas
Medical Society, the AMS Pen-
sion Plan, and MEFFA to deter-
mine every instance where AMS'
monies are invested in tobacco
companies, their subsidiaries,
and/or mutual funds holding to-
bacco stocks and bonds. A re-
port will be made to the Council
at its next meeting at which time
consideration will be given to the
divestment of all tobacco related
stocks, bonds and mutual funds.
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Do the "Write" Thing!
We're always looking for interesting and informative
articles for The Journal. If you have a topic that you
think would be of interest to your peers, please submit
it for consideration to:
Managing Editor
The Journal of the Arkansas Medical Society
P.O. Box 5776
Little Rock, AR 72215
(501)224-8967 (800)542-1058
Volume 93, Number 1 - June 1996
9
^Professional iJ^otection Sxclusively since 1899
To reach your local office, call 800-344-1899.
AMS Newsmakers
Chancery Judge John Norman Harkey (right) shakes hands with
Dr. J.R. Baker after swearing him in for an 8-year term on the
Arkansas State Medical Board.
Dr. James E. McDonald, II,
an ophthalmologist in Fayetteville,
was recently elected for a one-
year term to the board of direc-
tors of the American College of
Eye Surgeons.
Dr. J.R. Baker, a family practice physician in
BatesvUle, was recently appointed to an eight-year term
on the Arkansas State Medical Board by Gov. Jim Guy
Tucker.
Dr. K. Scott Malone, who
is completing his residency in
physical medicine and rehabili-
tation at UAMS this month,
was recently awarded an AMA
Policy Promotion Grant for the
Greater Friendship, Inc., Light-
house Project. The $500 grant
will be used to provide educa-
tional materials for drug and al-
cohol abuse programs, AIDS
Awareness Training, teen preg-
nancy counseling and community health fairs with the
target population being the Granite Mountain com-
munity of the City of Little Rock, home of the Light-
house Project's base operations. With the help of the
AMA and AMS, Dr. Malone has participated as a
Glaxo-Wellcome Health Policy Scholar and State Del-
egate to the Resident Physician Section of the AMA.
He will continue his training in Birmingham, Alabama,
as a fellow at the American Sports Medicine Institute.
Dr. Lawrence Schemel, a
family practitioner in
Springdale, was recently certi-
fied by the Federal Aviation Ad-
ministration to perform flight
physicals for second- and third-
class medical certificates and
student pilot certificates.
Dr. Carl L. Williams, a car-
diovascular surgeon in Fort
Smith, recently attended the 9*'"
International Congress of
Endovascular Interventions
sponsored by the Arizona
Heart Institute in Scottsdale.
The Physician's Recogni-
tion Award is awarded each
month to physicians who have
completed acceptable programs
of continuing education. Re-
cipients for the month of April
1996 are: Paul John Baxley,
Benton; Thomas Henry Benton,
Salem; Sandra D. Bruce-
Nichols, Little Rock; Carlton Lee Chambers, Harrison;
Bernard Louis Fioravanti, Rogers; Noland Harrison
Hagood, Arkadelphia; Paula Marie Lynch, Little Rock;
David Henderson Mosley, Camden; Nick J. Paslidis,
Little Rock; Bharathi Rangaswami, Helena; Roland
Reynolds, Newport; David R. Tapley, Hot Springs
National Park; William Perry Welch, Harrison; and
Phillip Lee White, Murfreesboro.
Lawrence Schemel, M.D.
James E. McDonald, M.D.
Volume 93, Number 1 - June 1996
11
Riverside Motors, Inc.
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666-9457 & 1-800-457-6226
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John CrenshaWf M.D.
1996-1997 President
Arkansas Medical Society
Pine Bluffy Arkansas
Volume 93, Number 1 - June 1996
13
Dr. Crenshaw takes his
oath of office with Dr.
Armstrong at his side.
Inaugural Address
John Crenshaw, M.D.
President 1996-1997
Dr. Armstrong, fellow physicians. Alliance mem-
bers, and guests, I am overwhelmed by this honor
bestowed on me. I appreciate our prior leadership
which join me at the podium and am excited to add
my name to this elite group!
As most of you know, I practice internal medicine
in Pine Bluff. My earliest roots are in rural Tennessee,
and my formal training was in Memphis prior to adopt-
ing and being adopted by the Razorbacks. I have great
admiration for the American way, which permits an
individual physician, such as myself, to develop the
mode of medical practice and lifestyle tailored to my
personal preferences. Still I have the privilege and
opportunity of influencing the practice and reputation
of our profession. I believe the greatest honor is to be
recognized by one's peers.
Age and maturity aid in appreciating traditions. I
intend to follow the tradition of a short inaugural
speech, highlighting current medical problems. The
title of this 120'*’ annual session is "Mastering
Medicine's Challenges."
Managed Care - Unquestionably the greatest threat
to medicine, as most of us are trained to treat patients.
Physicians struggle daily, attempting to adapt to the
changing environment of managed care. And we all
remember from our early training and rotation through
pediatrics: The only persons who welcome change are wet
babies. It is human nature to resist change and to cling
to the familiar - our comfort zones. The "Management
of Care" would be a more suitable name, for its synonyms
include rationing, capitation, gate keeping, and risk
sharing. These are confusing concepts; legalese com-
plicated by changing rules and regulations. The os-
trich approach will not do. Managed Care is here to
stay. Oh there will be evolution, redefinition, and new
names, but my friends and colleagues, a rose is a rose
is a rose. Instead of the government leading us to un-
familiar, shaky grounds, the medical profession
should lead the government in developing that elu-
sive level playing field where physicians can engage
in fair competition for the right to manage the man-
agement of our patients' care.
When Lonnie Bristow addressed the House of
Delegates yesterday, he used the analogy of the medi-
cal profession, trying to steer the government in its
attempts to control our practice of medicine. He used
the comparison with the bobsled and even we south-
ern arch conservatives realize there are no effective
breaks on bobsleds.
Medicare began in 1965 as I completed residency.
Fear gripped our hearts as we anticipated the dreaded
dragon of socialized medicine, whose unwelcome ar-
rival would take less than a decade. My training was
to care for sick persons. This task alone is a full-time
job. Additionally, we have encountered vice-like pres-
sure to over-utilize cost effectiveness and to under-
utilize advanced technology. Unfortunately we now
need to understand outliers, adverse selection, and
complex underwriting regulations as thoroughly as an
insurance executive does. Consequently, these over-
Volume 93, Number 1 - June 1996
15
bearing restrictions influence the practice of medicine,
and they have an impact on the economics of our
lifestyle.
In 1992, the Council of the Arkansas Medical Soci-
ety established the Arkansas Managed Care Organiza-
tion (AMCO) as a statewide PPO. Obviously, this ven-
ture has served its purpose well with 1,850 physician
providers. Today, some of our members feel we should
"move to the next level" and establish an HMO. I
strongly believe the Arkansas Medical Society is an
association of physicians. Therefore, we should remain
separate from any managed care organization. The
AMS represents all the physicians in Arkansas and
should not align with any specific group or program
in competition with another. My desire is that AMCO
will continue to thrive in the arena of managed care. I
strongly support the decision made yesterday by the
Council and the House of Delegates for the AMS to
disassociate from AMCO. Hopefully, this separation
will not create polarization or ill will from its constitu-
ents. I consider this my superlative summons this year
as your President.
A second challenge, vague to define, yet insidi-
ous, is apathy. Quoting Pogo, "We have met the enemy,
and he is us!" There are approximately 7,500 licensed
physicians m Arkansas and 4,500 practicing physicians.
Last year, we had only 3% or 150 physicians attend
this session. Tonight, millions are attending. Jerry
Mann, as Annual Session Chairman, the AMS staff,
and I have departed from tradition, attempting to en-
courage more participation. Tonight represents the first
time in which the President's Reception has occurred
before the election. I hope the House of Delegates elect
me to this office tomorrow morning as scheduled. Oth-
erwise, I feel no obligation to pay for the dinners of
my friends and family as promised!
We have all been reminded of the ancient tradi-
tion of torch bearers as preparation for the Olympic
Games has begun. We must work hard to involve more
young physicians in this organization by empowering
and entrusting to them positions of responsibility that
provide leadership development. We are their torch
bearers! The Young Physicians Organization is effec-
tive and deserves our immutable support. The OSMAP
meeting (a.k.a. President's Club) is patterned after the
AMA, serving as a vehicle for county society presi-
dents and specialty presidents to meet, discuss, and
influence the progress of our organization.
My life was molded in an effective Christian home
where the values of contributing both financially and
personally to God through the church were demon-
strated. Similarly, I believe physicians educated pri-
marily with state funds inherit an obligation to con-
tribute their time, talent, and energy to the betterment
of our profession. The Hippocratic Oath states: "I will
follow that system of regime which, according to my
ability and judgment, I consider for the benefit of my
patients and abstain from whatever is deleterious or
mischievous." My interpretation of this doctrine causes
me to believe that friction and factions within the
medical community - local, state and national - indi-
cate a malignancy of the practice of medicine. Looking
forward toward the rapidly approaching 21®‘ century
and its unimaginable challenges, this malignancy will
prove to be life threatening. It is imperative that we
bond together and unify our efforts and, yet, respect
the diversity of opinions. To quote Martin Luther King,
"We must all learn to live together as brothers or we will
perish as fools." The Crenshaw paraphrase states, "We
must all stick together or we will hang separately!" This
remains the only practical strategy for defeating the
"divide and conquer" tactics in which we are em-
broiled.
Remember the theme of this session - "Mastering
Medicine's Challenges." I have attempted to overview
the most pressing challenges from my perspective.
Patients demand and deserve quality health care that
is affordable and accessible. We are obligated to meet
these expectations and demands despite accompany-
ing harsh, political, and fiscal restraints. These trouble-
some twins dictate our practice of medicine while cast-
ing a pall upon our daily living. We must adopt the
Chinese symbol for change if we expect to survive this
oppression. Two characters from the Chinese language
are combined - the character for danger and the char-
acter for opportunity. Translated, it signifies change.
It is incumbent upon us to envision opportunity com-
bined with these potentially dangerous changes.
While we may not endorse each action of the AMA,
I advocate pledging a unified support to the national
leaders who are attempting reorganization to more
effectively shape the policies of organized medicine. I
admonish you to continue your participation in this
society and other grass roots organizations. I charge
you to encourage your fellow physicians to become
more involved in our society for the accomplishment
of the mission and the vision. As your President,
acutely aware of my imperfections, I humbly and grate-
fully accept this position as President of the Arkansas
Medical Society. I offer to you my pledge to execute
the responsibilities entrusted to me with courage, char-
acter, and commitment during my reigning year.
16 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Dr. Crenshaw with his wife Donna
AMS President
Profile
Dr. Crenshaw with family members.
John Crenshaw^ M.D.
Dr. Crenshaw, a physician of internal medicine, has been in private practice at Medical Associates,
P.A., in Pine Bluff since 1979. From 1967 to 1978, he was with The Doctors Clinic, P.A., in Pine Bluff. In
1961, Dr. Crenshaw graduated from the University of Tennessee College of Medicine at Memphis. Fie
then completed a year-long rotating internship with the City of Memphis Hospital and a three-year
internal medicine residency with the Veterans Administration Hospital in Memphis. From 1965 to 1967,
he was Captain of the Army Medical Corps in Ft. Leonard Wood, Missouri.
For the past twenty-nine years. Dr. Crenshaw has been affiliated with Jefferson Regional Medical
Center where he is currently a Board of Directors member and previously served as Chief of Staff and
Chairman of multiple committees.
He is a member of the American Medical Association and the American College of Physicians. He
is a past president of the Jefferson County Medical Society and the Arkansas Society of Internal Medi-
cine (ASIM). In addition, he is a past chairman of ASIM's Medical Liability Committee and member of
the Society's Laboratory Committee. With the Arkansas Medical Society, Dr. Crenshaw served as presi-
dent-elect in 1995-96, speaker of the house and on various committee chairmanships.
Dr. Crenshaw is a member of First United Methodist Church, where he has served as chairman of
the Administrative Board, Trustees and Finance Committee. He is a member of the Trinity Village Board
of Directors and a previous Board of Directors member for the Chamber of Commerce and United Way.
Dr. Crenshaw and his wife, Donna, have two grown children (a son and a daughter) and three
grandchildren.
Volume 93, Number 1 - June 1996
17
1st Feature Session
The Honorable Bill Kennemer and
Renee Paper, R.N., C.C.R.N., spoke during
the First Feature Session about “A Patient's
Right to Know... Curbing the Abuses of
Managed Care.” Kennemer, sponsor of the
Patient Protection/Full disclosure Act, was
elected to the Oregon State Senate in 1987.
He has a private practice in Clinical
Psychology.
Paper, Program Director for the
Hemophilia Foundation of Nevada, is the
Founding Board Member of the Citizens for
the Right to Know Coalition.
Shuffield Lecture
Joel Blackwell of the Issue Management Company in
Cornelius, N.C., was the featured speaker at the Shuffield
Luncheon on Friday, May 3. His talk was titled "Personal
Political Power." Blackwell has worked as a consultant and
trainer for associations since 1985. His presentation showed
how to develop positive attitudes and enthusiasm for
lobbying, politics and PACs; build long term relationships
with elected officials; and deliver a concise, personal
version of the association's message on issues.
Keynote Address
Lonnie R. Bristow, M.D., President of the American
Medical Association, gave the keynote address at the House
of Delegates meeting on Thursday, May 2. He has been a
member of the AMA Board of Trustees since 1985. Before
his election to the Board, he served as a delegate to the AMA
from the American Society of Internal Medicine. Bristow is
a diplomate of the Amercian Board of Internal Medicine and
a master of the American College of Physicians.
1996 Convention Keynote Speakers
1996 Convention Keynote Speakers
2nd Feature Session
Joseph M. Beck II, M.D., Sandra B.
Nichols, M.D., and William W. Stead,
M.D., spoke during the Second Feature
Session about "Infectious Diseases: An
Arkansas Focus." Beck, an oncologist in
private practice in Little Rock, is Chairman
of the AMS Task Force on AIDS. He also
serves as Chairman of the St. Vincent
Infirmary - Bloodbome Disease Committee
and is a member of the Arkansas Depart-
ment of Health AIDS Advisory Committee.
Nichols has been the Director of the
Arkansas Department of Health since 1994.
She is an Officer of the Department of
Health and Human Services, Food and Drug
Administration and is on Gov. Jim Guy
Tucker's Task Force on Health Care
Reform.
Stead, Director of the Tuberculosis
Program at the Arkansas Department of
Health, has served as a consultant for TB
control in prisons in Minnesota and New
Jersey. He was a member of the Advisory
Council for Elimination of TB for the
Centers for Disease Control from
1987-1991.
3rd Feature Session
Russell D. Harrington, Jr.,
President of Baptist Health in Little
Rock, and Ellen A. Pryga, Director of
the Division of Policy Development at
the American Hospital Association in
Washington, D.C., spoke during the
Third Feature Session about "Managed
Care: Confronting and Dealing With the
New Realities."
Harrington is a Fellow in the
American College of Healthcare Execu-
tives and is a past chairman of the
Arkansas Hospital Association. He
serves on Gov. Tucker's Task Force on
Health Care Reform and is a member of
the Health Services Commission.
Pryga has worked for the American
Hospital Association for more than 25
years. Currently, her work is focused on
health care reform and the changing role
of hospitals as they evolve into commu-
nity-based health care delivery systems.
^ I
1996 Arkansas Medical Society Annual Session
Officers
First
Session
Second
Session
Speaker
Anna Redman
present
present
Vice Speaker
Kevin Beavers
present
-
President
James Armstrong
present
present
President-elect
John Crenshaw
present
present
Vice President
Joe V. Jones
present
present
Secretary
Mike Moody
present
present
Treasurer
Lloyd Langston
present
-
Councilors
District 1:
Joe Stallings
present
-
Dwight Williams
present
-
District 2:
Lloyd Bess
-
present
Daniel Davidson
present
present
District 3:
Hoy B. Speer, Jr
present
present
P. Vasudevan
present
present
District 4:
John O. Lytle
present
-
Paul Wallick
present
present
District 5:
Wayne Elliott
present
-
Robert Nunnally
present
-
District 6:
George Finley
present
present
Michael Young
-
-
District 7:
Robert McCrary
-
present
Brenda Powell
present
present
District 8:
David Barclay
-
-
Joseph Beck
-
-
Paul Cornell
present
present
Anthony Johnson
present
present
William Jones
present
present
Charles Logan
present
present
Jerry Mann
present
present
J. Mayne Parker
present
present
John L. Wilson
-
-
District 9:
David Davis
-
-
Robert Langston
present
present
William McGowan - present
District 10: Gerald Stolz present present
Paul Wills
Morton Wilson present present
Past Presidents
1979-1980
A. E. Andrews
present
-
1971-1972
C. Stanley Applegate -
-
1993-1994
Glen F. Baker
present
-
1985-1986
John P. Burge
present
present
1983-1984
Asa A. Crow
present
-
1964-1965
C. Randolph Ellis
present
-
1869-1970
Ross E. Fowler
-
-
1951-1952
Charles R. Henry
-
-
1982-1983
1988-1989
Morriss M. Henry
John M. Hestir
- present
present
present
1990-1991
William N. Jones
present
-
1987-1988
W Ray Jouett
-
present
1976-1977
Albert S. Koenig
-
-
1994-1995
James M. Kolb, Jr.
present
present
1977-1978
Payton Kolb
present
-
1980-1981
Kemal E. Kutait
-
-
1992-1993
J. Larry Lawson
-
present
1986-1987
Ken Lilly
-
-
Honorary
C. C. Long
-
-
1967-1968
Joseph Norton
-
-
1974-1975
Ben Saltzman
-
-
1981-1982
Purcell Smith
-
-
1968-1969
H. W. Thomas
present
-
1975-1976
T. E. Townsend
-
-
1991-1992
George Warren
present
-
1989-1990
James Weber
-
-
1984-1985
Charles Wilkins
-
-
1973-1974
John Wood
-
-
1978-1979
George Wynne
-
-
House of Delegates Composition
First Second
County Delegates Session Session
Arkansas (1)
Ashley (1)
Baxter (2)
Benton (4)
Boone (1)
Bradley (1)
Carroll (1)
Chicot (1)
Clark (1)
Cleburne (1)
Columbia (1)
Conway (1)
NOT REPRESENTED
NOT REPRESENTED
John Guenthner present
Robert Baker present
NOT REPRESENTED
Jim Crider present
NOT REPRESENTED
Oliver Wallace present
NOT REPRESENTED
NOT REPRESENTED
Jerry Thomas present
NOT REPRESENTED
NOT REPRESENTED
present
present
present
present
Craighead
/Poinsett (7)
Crawford (1)
Crittenden (2)
Cross (1)
Dallas (1)
James Basinger
Tim Dow present
Joe Stallings
Ken Tidwell present
Don Vollman present
NOT REPRESENTED
G. Edward Bryant present
NOT REPRESENTED
Don Howard present
present
present
present
present
Desha (1)
Drew (1)
Faulkner (2)
Franklin (1)
Garland (6)
NOT REPRESENTED
Harold Wilson present present
NOT REPRESENTED
David Gibbons present
Kevin Hale present
House of Delegates Composition (continued)
Grant (1)
NOT REPRESENTED
Anthony Johnson
present
-
Greene/Clay (1)
Roger Cagle
present
present
Carl Johnson
present
-
Hempstead (1)
NOT REPRESENTED
Gail Jones
-
-
Hot Spring (1)
NOT REPRESENTED
David King
present
present
Howard/Pike (1)
Robert Sykes
present
present
Dean Kumpuris
-
-
Independence (2’
J.R. Baker
present
present
J.F. Kyser
-
present
William Waldrip
-
present
Marvin Leibovich
present
-
Jackson (1)
Mufiz Chauhan
present
present
Steve Magie
present
-
Jefferson (5)
Simmie Armstrong present
-
Jane McKinnon
-
present
Omar Atiq
present
present
David Mumme
-
-
David Jacks
present
present
Fred Nagel
-
-
George Roberson -
present
George Norton
-
-
Jerrye Woods
present
present
Richard Peek
-
present
Johnson (1)
NOT REPRESENTED
Lafayette (1)
Brad Harbin
present
present
.
Carl Raque
present
present
Lawrence (1)
Robert Quevillon
present
present
John Redman
present
present
Lee (1)
NOT REPRESENTED
Ashley Ross
present
present
Little River (1)
NOT REPRESENTED
Ted Saer
-
-
Logan (1)
NOT REPRESENTED
Bruce Schratz
present
present
Lonoke (1)
NOT REPRESENTED
Frank Sipes
present
present
Medical Student
Vanessa McKinney
-
present
Kemp Skokos
-
-
Miller (3)
Joseph Robbins
present
-
Duane Velez
-
-
Robert McRaney
-
-
Samual Welch
-
-
Herbert Wren
-
-
Randolph (1)
NOT REPRESENTED
Mississippi (1)
Joe V. Jones
present
-
Saline (2)
NOT REPRESENTED
Merrill Osborne
-
present
Sebastian (11)
Randy Ennen
-
-
Monroe (1)
NOT REPRESENTED
R. Cole Goodman -
-
Nevada (1)
NOT REPRESENTED
Peter Irwin
-
-
Ouachita (1)
William Dedman
-
present
Greg Jones
present
-
Phillips (1)
Francis Patton
present
present
Mike Berumen
present
-
Polk (1)
David Fried
present
present
Robert Knox
-
-
Pope (3)
David Murphy
present
present
John Lange
-
-
Pulaski (37)
William Ackerman
present
present
Jack Magness
-
-
D. B. Allen
-
-
Eugene Still
-
-
Ray Biondo
present
-
John Swicegood
present
-
Bob Cogburn
-
-
John Wells
-
-
Michael Cope
-
-
Sevier (1)
NOT REPRESENTED
David Coussens
-
-
St. Francis (1)
NOT REPRESENTED
Gilbert Dean
present
-
Tri-County (1)
NOT REPRESENTED
Philip Deer, III
-
-
Union (2)
NOT REPRESENTED
Brad Diner
present
-
Van Buren (1)
John A. Hall
present
-
Gilbert Dean
present
-
Washington (7)
David Davis
-
-
Shirley DesLauriers
present
Anthony Hui
-
present
Tom Eans
present
present
Sanford Hutson
present
present
Jim English
present
-
William McGowan
-
-
Charles Fitzgerald
-
Michael Morse
present
-
Thomas Frazier
present
-
Danny Proffitt
-
-
Fred Henker
present
present
White (2)
Mark Brown
-
-
Reid Henry
-
-
David Covey
present
present
Steve Hodges
-
-
Woodruff (1)
NOT REPRESENTED
Tom Jansen
-
-
Yell (1)
James Maupin
present
present
Volume 93, Number 1 - June 1996
21
House of Delegates
First Session - May 1., 1996
Speaker of the House Anna Redman called the
meeting to order on Thursday, May 2, 1996, at the
120th annual meeting of the Arkansas Medical Soci-
ety. Dr. Payton Kolb asked for a moment of silence in
memory of the physicians, physicians' spouses, and
Alliance members who had passed away in the past
year and gave the invocation.
Dr. Redman introduced Mrs. Evelyn Thomas, AMS
Alliance President; and Mrs. Bobby Illackshear, AMS
Alliance AMA-ERF Chairman; Mrs. Susie Reeder, AM A
Alliance Membership Committee Chairman; and Mrs.
Sancy McCool, Southern Medical Association Auxil-
iary President-elect.
Mrs. Evelyn Thomas presented Dr. I. Dodd Wil-
son, Dean, University of Arkansas College of Medi-
cine, with two grants from the AMA Education and
Research Foundation. The $2,225.00 grant is intended
for the pursuit of excellence in the medical school's
programs and $7,546.00 grant is restricted to financial
assistance for medical students.
Dr. Redman announced there were 96 voting mem-
bers in attendance.
Upon motion, the House approved the minutes
of the 119th annual session as published in the June
1995 issue of The Journal of the Arkansas Medical Society.
Dr. Charles Logan presented plaques to: Dr. Paul
Wallick who served as a councilor from 1984 to 1996;
Dr. Jerry Mann who served as a councilor from 1989
to 1996; Dr. Robert Langston who served as a coun-
cilor from 1984 to 1996; Dr. Morton Wilson who served
as a councilor from 1985 to 1996; and Dr. Robert
Nunnally who served as a councilor from 1992 to 1996.
Plaques will be sent to Dr. Janet Titus who served
On behalf of the Arkansas Health Care Access Foundation, Inc.,
Dr. Joe Colclasure (at the podium) presents the 1996 Spirit of
Service Award to Dr. Kevin Hale (at left sta^^ding) of Hot Springs.
22
as a councilor from 1992
to 1996 and Dr. Tho-
mas Hollis who served
as a councilor from 1986
to 1996.
Dr. James Arm-
strong presented a
plaque to Dr. Charles
Logan who served as
councilor to the Arkan-
sas Medical Society
from 1982 to 1996 and
as Chairman of the
Council from 1991 to 19%.
Dr. Joe Colclasure
presented the 1996
Spirit of Service Award
on behalf of the Arkansas Health Care Access Founda-
tion to Dr. Kevin Hale of Hot Springs for being an
outstanding volunteer.
Dr. Redman announced the vacancies on the state
boards and reminded the members from the counties
in the districts and the Nominating Committee to meet
immediately following the adjournment of the House
to vote for three nominees for each vacancy. Vacan-
cies will occur December 31, 1996 in the first congres-
sional district and member-at-large position of the
Arkansas State Board of Health. A vacancy will occur
December 31, 1996, in the first congressional district
of the Arkansas State Medical Board.
Dr. Redman announced the 1996-1997 Nominat-
ing Committee members: District #1: Dr. Merrill
Osborne, BlytheviUe; District #2: Dr. Daniel Davidson,
Searcy; District #3: Dr. Francis Patton, Helena; District
#4; Dr. Harold Wilson, Monticello; District #5: Dr.
Robert Nunnally, Camden; District #6: Dr. A. E.
Andrews, Texarkana; District #7: Dr. Kevin Hale, Hot
Springs; District #8: Dr. John Wilson, Little Rock; Dis-
trict #9: Dr. Carlton Chambers, Harrison; and District
#10: Dr. Gerald Stolz, Russellville.
Dr. Redman announced that the Reference Com-
mittee meetings will begin at 9:30 a.m., Friday morn-
ing, May 3.
Dr. John Burge introduced the keynote speaker
Dr. Lonnie Bristow, President of the American Medi-
cal Association. Dr. Bristow gave an update of the
AMA's activities and discussed the need for physi-
cians to be unified.
There being no further business the meeting ad-
journed until Saturday, May 4.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Dr. William N. Jones of Little Rock.
House of Delegates
Final Session - May 4, 1996
Speaker of the
House Anna Redman
called the meeting to
order on Saturday, May
4, 1996, and reported
there were 79 voting
members present.
Speaker Redman
asked Dr. Carlton
Chambers, Chairman
of the Nominating
Committee, to present
the slate of officers:
President-elect:
Charles Logan, M.D.,
Little Rock
Vice President: Jim
Crider, M.D., Harrison
Treasurer: Lloyd Langston, M.D., Pine Bluff
Secretary: Mike Moody, M.D., Salem
Speaker of the House: Anna Redman, M.D., Pine Bluff
Vice Speaker of the House: Kevin Beavers, M.D.,
Russellville
Delegates to the AMA:
John Burge, M.D., Lake Village (1/1/97-12/31/98)
William Jones, M.D., Little Rock (1/1/97-12/31/98)
Alternate Delegate to the AMA:
James M. Kolb, Jr., M.D., Russellville (1/1/97-12/31/98)
John Hestir, M.D., DeWitt (1/1/97 - 12/31/98)
Dr. Anna Redman of Pim Bluff,
Speaker of the House of Delegates.
Councilors:
District 1:
District 2:
District 3:
District 4:
District 5:
District 6:
District 7:
District 8:
District 9:
District 10:
Dr. Charles
Dwight Williams, M.D., Paragould
Daniel Davidson, M.D., Searcy
Parthasarathy Vasudevan, M.D., Helena
Harold Wilson, M.D., Monticello
Fred Murphy, M.D., Magnolia
George Finley, M.D., Hope
Robert McCrary, M.D., Hot Springs
Brenda Powell, M.D., Hot Springs
David Barclay, M.D., Little Rock
John Wilson, M.D., Little Rock
Bruce Schratz, M.D., North Little Rock
Carlton Chambers, M.D., Harrison
William McGowan, M.D., Springdale
John Swicegood, M.D., Fort Smith
Gerald Stolz, M.D., Russellville
Logan was elected president-elect by
acclamation as were the other nominees. The House
of Delegates voted to elect Drs. Lloyd Langston and
David Barclay in their absence.
The next order of business was the reports from
the Reference Committees. The adoption of these re-
ports was approved and is printed in this, the June
1996 issue of The Journal of the Arkansas Medical Society.
The report of the Council was given by Dr. Charles
Logan, Chairman, and approved by the House to be
filed for information.
Dr. Redman announced the following nominees
for the state board positions: First Congressional Dis-
trict, Arkansas State Board of Health: Drs. Dwight
Williams, Paragould; Roger Cagle, Paragould; and Joe
Jones, Blytheville; Member-at-Large Position, Arkan-
sas State Board of Health: Drs. James Maupin, Little
Rock; Harold Wilson, Monticello; and Joe Jones,
Blytheville; First Congressional District, Arkansas State
Medical Board: Drs. Owen Clopton, Jonesboro; Trent
Pierce, West Memphis; and Joe Jones, Blytheville.
Dr. Redman also announced that Dr. Carlton
Chambers, Harrison, had been chosen Chairman of
the Nominating Committee and Dr. Gerald Stolz,
Russellville, Secretary.
Dr. James Armstrong gave a farewell address to
the members and guests. This address is printed in
this, the June 1996 issue of The Journal of the Arkansas
Medical Society.
There being no further business the meeting adjourned.
Dr. Charles Logan is escorted to the podium as President-elect
by Dr. Larry Lawson and Dr. John Burge.
Volume 93, Number 1 - June 1996
23
1996-1997 Arkansas Medical Society Officers
John Crenshaw, M.D., Pine Bluff, President
Charles Logan, M.D., Little Rock, President-elect
James Crider, M.D., Harrison, Vice President
James Armstrong, M.D., Ashdown, Immediate Past President
Mike Moody, M.D., Salem, Secretary
Lloyd Langston, M.D., Pine Bluff, Treasurer
Anna Redman, M.D., Pine Bluff, Speaker, House of Delegates
Kevin Beavers, M.D., Russellville, Vice Speaker, House of Delegates
AMS Executive Committee Members
Gerald Stolz, M.D., Russellville, Chairman
John Crenshaw, M.D., Pine Bluff, President
Charles Logan, M.D., Little Rock, President-elect
Mike Moody, M.D., Salem, Secretary
Lloyd Langston, M.D., Pine Bluff, Treasurer
James Armstrong, M.D., Ashdown, Immediate Past President
Councilors and Councilor Districts
First District
Dwight Williams, M.D., Paragould (1998); Joe Stallings, M.D., Jonesboro (1997) - Clay, Craighead,
Crittenden, Greene, Lawrence, Mississippi, Poinsett, Randolph
Second District
Lloyd Bess, M.D., Batesville (1997); Daniel Davidson, M.D., Searcy (1998) - Cleburne, Conway, Faulkner,
Fulton, Independence, Izard, Jackson, Sharp, Stone, White
Third District
Hoy B. Speer Jr., M.D., Stuttgart (1997); P. Vasudevan, M.D., Helena (1998) - Arkansas, Cross, Lee,
Lonoke, Monroe, Phillips, Praire, St. Francis, Woodruff
Fourth District
John O. Lytle, M.D., Pine Bluff (1997); Harold Wilson, M.D., Monticello (1998) - Ashley, Chicot, Desha,
Drew, Jefferson, Lincoln
Fifth District
Wayne Elliott, M.D., El Dorado (1997); Fred Murphy, M.D., Magnolia (1998) - Bradley, Calhoun, Cleve-
land, Columbia, Dallas, Ouachita, Union
Sixth District
George Finley, M.D., Hope (1998); Michael Young, M.D., Prescott (1997) - Hempstead, Howard, Lafayette,
Little River, Miller, Nevada, Pike, Polk, Sevier
Seventh District
Brenda Powell, M.D., Hot Springs (1997); Robert McCrary, M.D., Hot Springs (1998) - Clark, Garland,
Grant, Hot Spring, Montgomery, Saline
Eighth District
Vacant (1997); Paul Cornell, M.D., Little Rock (1997); David L. Barclay, M.D., Little Rock (1998); Joseph
M. Beck II, M.D., Little Rock (1997); William N. Jones, M.D., Little Rock (1997); J. Mayne Parker, M.D.,
Little Rock (1997); John L. Wilson, M.D., Little Rock (1998); Anthony Johnson, M.D., Little Rock (1997);
Bruce Schratz, M.D., North Little Rock (1998) - Pulaski
Ninth District
Carlton Chambers, M.D., Harrison (1998); William McGowan, M.D., Springdale (1998); David Davis, M.D.,
Fayetteville (1997) - Baxter, Benton, Boone, Carroll, Madison, Marion, Newton, Searcy, Van Buren, Wash-
ington
Tenth District
John Swicegood, M.D., Fort Smith (1998); Gerald A. Stolz, M.D., Russellville (1998); Paul 1. Wills, M.D.,
Fort Smith (1997) - Crawford, Franklin, Johnson, Logan, Perry, Pope, Scott, Sebastian, Yell
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Reference Committee #1
David Jacks^ M.D., Chairman
Reference Committee #1 was composed of: Dr.
John Ashley, Newport; Dr. Jerry Fontenot, Little Rock;
Dr. Derek Lewis, Little Rock; Dr. David Murphy,
Russellville; Jeff Marotte, Medical Student Represen-
tative; and Dr. David Jacks, Pine Bluff, Chairman.
This Reference Committee gave careful consider-
ation to the following item: Resolution from the Ar-
kansas Academy of Family Physicians Concerning
cola's Accreditation Program for Laboratories. This
Reference Committee offers the following substitute
resolution:
Whereas, the Commission on Office Laboratory
Accreditation (COLA) is the only not for profit edu-
cation and accreditation organization specifically de-
signed to meet the needs of physician directed labo-
ratories that are practice based and was founded by
the American Academy of Family Physicians, the
American Medical Association, the American Society
of Internal Medicine, and the American Association
of Pathologists; and
Whereas, the Commission on Office Laboratory
Accreditation (COLA) is approved by the Health Care
Financing Administration as an educational alterna-
tive to federal certification of laboratories under CLIA
88; therefore be it
Resolved, that the Arkansas Medical Society en-
dorse the accreditation program for laboratories of the
Commission on Office Laboratory Accreditation; and
be it further
Resolved, that the Arkansas Medical Society pub-
licize information about the Commission on Office
Laboratory Accreditation and encourage physicians
to seek clinical laboratory accreditation through COLA
as their peer review alternative to federal certification
under CLIA 88.
Resolved, that the Arkansas Medical Society ac-
knowledge the accreditation program for laboratories
of the Commission on Office Laboratory Accredita-
tion as an alternative to federal certification under
CLIA 88; and be it further
Resolved, that the Arkansas Medical Society make in-
formation about the Commission on Office Laboratory
26
Accreditation available to its membership.
This Reference Committee recommends the adop-
tion of the substitute resolution.
This Reference Committee carefully reviewed and
discussed the following reports printed in the April
issue of The Journal of the Arkansas Medical Society.
Arkansas Medical Society 1996 Budget, Dr. Jerry
Mann, Chairman; Report of the Executive Vice Presi-
dent, Ken LaMastus, Executive Vice President; Physi-
cians' Health Committee, Dr. Joe Martindale, Chair-
man; AMS Management Company, Janell Mason, COO.
Reference Committee #1 recommends that these
reports be filed for information.
This Reference Committee gave careful consider-
ation to the following items and request that they be
considered separately: Annual Session Committee, Dr.
Jerry Mann, Chairman; CME Accreditation Commit-
tee, Dr. Steve Strode, Chairman; and Report of the Coun-
cil, Dr. Charles Logan, Chairman.
This Reference Committee recommends that the
report of the Annual Session Committee be filed for
information and that Dr. Mann and the Arkansas Medi-
cal Society staff be commended for their hard work in
preparing for the Annual Sessions each year.
This Reference Committee recommends that the
report of the CME Accreditation Committee be filed
for information and that the AMS President take into
consideration the logistical and time commitments nec-
essary to adequately carry out the mission of this com-
mittee when making committee appointments.
This Reference Committee recommends that the
report of the Council be filed for information and that
Dr. Logan be commended for serving as Chairman of
the Council for the last five years and that the House
of Delegates join our committee in a standing ovation
in honor of Dr. Logan.
This concludes the report of Reference Committee
#1. The chairman wishes to thank those who appeared
before the Committee, members of the Committee, and
David Wroten and Nadine Gentry of the AMS staff for
their assistance.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reference Committee #2
Kim Graves^ M.D., Chairman
Reference Committee #2 was composed of: Dr.
Omar Atiq, Pine Bluff; Dr. Brad Harbin, Stamps; Dr.
Robert Sykes, Nashville; Richard White, Medical Stu-
dent Representative; and Dr. Kim Graves, Clarksville,
Chairman.
This Reference Committee carefully reviewed and
discussed the following reports printed in the April
issue of The Journal of the Arkansas Medical Society: Medi-
cal Education Foundation for Arkansas, Dr. Martin
Eisele, President; Medical Services Review Commit-
tee, Dr. Joe Stallings, Chairman; AMS Medical Stu-
dent Section, Brian Meyer, Immediate Past President;
Ouachita County Medical Society, Dr. Robert Nunnally,
Secretary/Treasurer; Pulaski County Medical Society,
Fred Reddoch, Executive Director; Arkansas Health
Care Access Foundation, Dr. Joe Colclasure, President;
and Arkansas State Medical Board, Peggy Pryor Cryer,
Executive Secretary.
Reference Committee #2 recommends that these
reports be filed for information.
This Reference Committee gave careful consideration
to the following items and request that they be consid-
ered separately: Ad hoc Committee on Managed Care,
Dr. Glen Baker, Chairman; and Arkansas Department
of Health, Dr. Sandra Nichols, Director.
This Reference Committee recommends that the
report of the Ad hoc Committee on Managed Care be
filed for information and that members of the Arkan-
sas Medical Society be educated about THG and the
relationship and the impact on the local AMCOs.
Many concerns were expressed about the issue of
home health and the need for physicians to be better
informed about their role in certifying home health
needs. This Reference Committee recommends that the
report of the Arkansas Department of Health be filed
for information; and that the Arkansas Medical Soci-
ety develop and provide information to educate phy-
sicians about their roles and obligations in home health;
and that Dr. Sandra Nichols be commended for her
exemplary service as Director of the Department of
Health.
This concludes the report of Reference Committee
#2. The chairman wishes to thank those who appeared
before the Committee, members of the Committee, and
David Wroten and Tina Wade of the AMS staff for their
assistance.
1996-1997 Council of the Arkansas Medical Society
1996-1997 Arkansas Medical Society Council Officers
Volume 93, Number 1 - June 1996
27
Report of the Council
May 2-3, 1996
The Council of the Arkansas Medical Society met
May 2-3, 1996, at the Excelsior Hotel in Little Rock.
The following business was received and transacted:
1. Upon motion the Council approved a resolution
authorizing the Board of Directors of the AMS Man-
agement Company to 1) sign a letter of intent with
THG Management Services for the purchase of the
AMS Management Company and complete the sale
according to those terms; 2) authorize the Board
to take the necessary steps to dissolve the corpo-
ration; and 3) encourage the AMCO's to execute
new management agreements with THG Manage-
ment Services.
2. Upon motion the Council approved the minutes
of the March 31, 1996 Council meeting.
3. The following reports were accepted for information:
AMS Membership Report, AMS Budget Report,
AMS Audit for 1995 and MEFFA Audit for 1995.
4. Dr. Lonnie Bristow, President of the American
Medical Association, greeted the Council members
and briefly discussed legislative issues in Wash-
ington regarding anti-trust and the AMA meeting
to be held in June.
5. Dr. William Jones discussed the AMA's recent
announcement concerning the divestment of all
tobacco related stocks, bonds, and mutual funds.
Upon motion, the Council voted for the Budget
Committee to undertake a comprehensive study
of investment portfolios of the Arkansas Medical
Society, the AMS Pension Plan, and MEFFA to
determine every instance where our monies are
invested in tobacco companies, their subsidiaries,
and/or mutual funds holding tobacco stocks and
bonds; and that a report be made to the Council at
our next meeting at which time the Council will
consider divestment of all tobacco related stocks,
bonds, and mutual funds.
6. Dr. Glen Baker gave an update on the new foun-
dation for the Physicians' Health Committee, the
Arkansas Medical Foundation.
7. Dr. William Jones discussed the new Medicare
HMO techniques for credentialing physicians by
requesting to review random office charts. Upon
motion the Council voted to refer this issue to the
Arkansas State Medical Board for investigation to
determine if this represents a breach of medical
ethics and the Medical Practices Act.
8. The Council made the following committee ap-
pointments:
Budget Committee: Gerald Stolz, Russellville and
Robert McCrary, Hot Springs.
Journal Editorial Board: reappointed Ben
Saltzman, Mountain Home, family practice and
reappointed Lee Abel, Little Rock, internal medicine.
Medical Education Foundation for Arkansas: re-
appointed Martin Eisele, Hot Springs.
Arkansas Medical Society Pension Plan Board of
Trustees: Wayne Elliott, El Dorado.
Committee on Position Papers: reappointed Roger
Cagle, Paragould, Chairman; reappointed Paul
Wills, Fort Smith; reappointed Paul Wallick,
Monticello; reappointed Martin Fiser, Little Rock;
and reappointed Peter Marvin, North Little Rock.
Medical Services Review Committee:
Family Practice: Kerry Pennington, Warren, Gen-
era/ Surgery: Samuel Landrum, Fort Smith, Obstet-
rics/Gynecology: Karen Kozlowski, Little Rock,
Internal Medicine and Pediatric Representatives: posi-
tions open pending reports from their organizations.
Pathology: Gerald Stolz, Russellville, Orthopaedic
Surgery: David Newbern, Little Rock
MSRC Subcommittee of Subspecialties:
Emergency Medicine: James Tutton, Benton
Nephrology: Ronald Hughes, Little Rock
Pediatric Allergy: Joseph Matthews, Little Rock
Physicians' Advisory Committee to Medicare:
Emergency Medicine: James Tutton, Benton
Family Practice: Kerry Pennington, Warren
General Surgery: Samuel Landrum, Fort Smith
Nephrology: Ronald Hughes, Little Rock
Obstetrics! Gynecology: Janet Cathey, Little Rock
Orthopaedic Surgery: D. Gordon Newbern, Little Rock
Pathology: Gerald Stolz, Russellville
Pediatric Representative: position open pending report
28 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
from their organization
Physicians' Health Committee: Stacey Johnson,
Mountain Home
9. Upon motion the Council approved a change to
the bylaws for the Physicians Advisory Commit-
tee for a term of three years and a member cannot
serve more than one term. This will coincide with
the MSRC bylaws.
10. Dr. Burge discussed the AMA Federation to be
voted on at the AMA House of Delegates meeting
in June and encouraged everyone to give AMS
delegates their comments.
11. Upon motion the Council approved requests for
dues exemption for life, emeritus, and affiliate
memberships for the physicians listed below.
Physician
Date of
Birth
First Year
In Practice
County
Membership
Berry, Frederick B.
04/21/27
1952
Hot Spring
LIFE
Browning, Donald G.
12/26/35
1968
Pulaski
AFFILIATE
Campbell, James W.
08/16/29
1958
Pulaski
EMERITUS
Chester, Robert L.
10/29/26
1956
Sebastian
EMERITUS
Chock, Helga E.
12/10/39
1979
Baxter
AFFILIATE
Cook, Charles
04/10/47
1974
Sebastian
AFFILIATE
Cornell, Paul J.
06/09/35
1965
Pulaski
EMERITUS
Darden, Lester R.
09/11/35
1961
Crawford
EMERITUS
Decker, Harold
01/09/32
1961
Washington
EMERITUS
Doyle, Edward
05/06/34
1964
Crawford
AFFILIATE
Dykstra, Peter C.
10/29/27
1953
Baxter
EMERITUS
Ellis, Homer G.
05/27/26
1956
Sebastian
LIFE
Garrison, James S.
11/27/37
1971
Faulkner
EMERITUS
Glenn, Wayne B.
01/25/32
1960
Pulaski
EMERITUS
Glover, W. Clyde
04/07/32
1958
Pulaski
EMERITUS
Goza, George M. Jr.
10/18/26
1978
Pulaski
AFFILIATE
Hardin, Robert
12/14/35
1965
Pulaski
AFFILIATE
Harris, Howard R.
09/20/25
1955
Desha
LIFE
Hayes, J. Harry Jr.
05/23/31
1962
Pulaski
AFFILIATE
Henderson, Francis M.
03/30/33
1963
Jefferson
EMERITUS
Jacks, John W.
01/04/23
1950
Benton
AFFILIATE
Keane, Patrick K.
07/19/44
1976
Benton
AFFILIATE
Kelley, Charles W.
03/24/28
1957
Columbia
EMERITUS
Kennedy, Charles H.
02/23/26
1953
Pulaski
LIFE
Langston, Robert H.
03/16/31
1960
Boone
EMERITUS
Lowry, James L.
12/16/38
1971
Clark
AFFILIATE
Mashburn, William R.
06/08/29
1961
Garland
AFFILIATE
McAlister, Joseph H.
05/02/25
1954
Washington
AFFILIATE
Miller, Donald L.
12/03/28
1960
Jefferson
EMERITUS
Mings, Harold H
09/29/32
1962
Sebastian
EMERITUS
Moose, John I.
04/15137
1966
Benton
EMERITUS
Nixon, William R.
05/02/26
1957
Jefferson
LIFE
Patton, Francis M.
11/26/27
1961
Phillips
EMERITUS
Peacock, Norman W. Jr.
08/19/18
1943
Little River
AFFILIATE
Purcell, Donald I.
12/06/26
1950
Greene/Clay
LIFE
Roberts, William J.
12/27/36
1964
Logan
AFFILIATE
Sanders, James W.
01/29135
1981
Craighead/Poinsett
EMERITUS
Sapiro, Gary S.
09/21/38
1972
Craighead/Poinsett
AFFILIATE
Schemel, William H.
05/03/33
1959
Sebastian
EMERITUS
Schultz, Wayne H.
06/15/26
1955
Union
LIFE
Ward, Hiram T.
11/26/25
1953
Howard/Pike
LIFE
Wikman, John H.
09/27/34
1960
Sebastian
EMERITUS
Williams, Rhys A.
01/02/29
1959
Boone
EMERITUS
Wright, John D.
08/15/25
1953
Saline
LIFE
Volume 93, Number 1 - June 1996
29
Farewell Address
James Armstrong, M.D.
President 1995-1996
Madam speaker, honored guests, members of the
House of Delegates, and visitors:
First of all, let me express my sincere appreciation
and thanks to Executive Vice President Ken LaMastus,
David Wroten, Lynn Zeno, Kay Waldo, and the entire
staff of the Arkansas Medical Society. My job this year
as president would have been impossible without their
expertise. We are, indeed, most fortunate to have a
group of people who are diligent, knowledgeable, and
dedicated to the successful performance of this orga-
nization. Their help and kindness have made my year
a genuine pleasure. Let me also express my gratitude
to the Executive Committee and to the Council for their
willingness to give of their time and judgment to re-
solve issues which have confronted us.
As the year during which I have had the honor of
serving as your president comes to a close, I would
like to reflect on some of the accomplishments of the
Society during this period and to discuss some of the
challenges which I envision will continue to confront
us in the future. The multitude and complexity of
changes which are occurring in the medical profes-
sion will continue to require study, understanding,
and re-evaluation of traditional tenets for us individu-
ally and for our medical organizations as a whole.
I would like to review with you some of the ac-
complishments of your Society during this past year.
The Arkansas Medical Society has represented the in-
terest of the medical profession in a multitude of pub-
lic hearings, workers' compensation debates. Medi-
care reform and other legislative issues. We were able
to successfully challenge and overturn a required
twelve-hour annual CME requirement by the Work-
ers' Compensation Commission. We took a major role
in a successful effort to reverse mandatory managed
30
care organizations for workers' compensation. We sent
a clear message to insurance companies through the
passage of the Any Willing Provider/Patient Protec-
tion Act that patients and their doctors should be in
control of health care, and we have coordinated a le-
gal defense fund to fight insurance companies' attempts
to challenge that act.
We have successfully lowered the statute of limi-
tations for lawsuits concerning treatment of minors,
thereby reducing medical liability exposure by fifty
percent. We have helped defeat a proposal allowing
independent practice and independent prescription
writing authority by Advanced Practice Nurses. We
have helped defeat plaintiff attorneys' efforts to in-
crease medical liability and exposure which would have
increased malpractice insurance premiums.
We have worked with the Arkansas Congressional
Delegation to reinstate separate payments for EKGs
and to eliminate reimbursement reductions for new
physicians under Medicare. We have monitored nearly
two thousand bills submitted during the 80th Arkan-
sas General Assembly. We have maintained contact
with the Arkansas Congressional Delegation in Wash-
ington, D.C., as they considered health care reform,
tort reform, and countless other federal rules and regu-
lations.
This Society has continued to operate the Medical
Education Eoundation for Arkansas, a private founda-
tion providing grants for speaker and medical items
needed for medical education. We have assisted over
seventy impaired physicians through the Physicians'
Health Committee and we established, in April of this
year, the Arkansas Medical Foundation to provide a
full-time office and medical director for the physicians'
health program. We have helped fund for the Arkan-
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
sas Medical Society Alliance monies for office space
and an executive secretary.
What must we expect to confront during this next
year? Certainly, state and national legislative sessions
will present a multitude of issues which will affect all
of us. Our strength has been in a unified effort by all
segments of our medical community. Efforts by oth-
ers outside our profession will try to exploit divisions
within us to accomplish agendas which may not re-
flect our best interest or that of our patients.
The Arkansas Medical Society must act to address
and coordinate the interests and actions of all of our
various components so our collective voice will remain
strong, influential, and unified in the political arena.
This society must recognize the new and changing
On behalf of the AMS^, Dr. Crenshaw
presents an alarm clock shaped like a
fishing reel to Dr, Armstrong, As Dr.
Crenshaw sounds the alarm^, everyone
listens as a fisherman casts a line.
patterns of practice and methods of health care deliv-
ery, and we must provide leadership and direction in
our professional efforts to continue to provide the high-
est quality of health care available an}nvhere in the world.
Each of us must remember our first and foremost
responsibility is to our patients. Regardless of prac-
tice arrangements, government regulations, or other
outside influences, our primary duty is to provide com-
passionate and quality health care to those who seek
our help.
It has been my privilege to serve this past year as
your president. This has been a most singular honor,
and I thank you. I trust you will continue to give your
support and cooperation to this society and to my suc-
cessor, Dr. John Crenshaw.
Dr. Crenshaw presents Dr.
Armstrong with a framed cover
from The Journal of the Arkansas
Medical Society.
Dr. Armstrong with his daughter,
Jimmie, son-in-law, Blane and his
wife, Judy.
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32
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas Medical Society Alliance
72nd Annual Session
AMSA Annual Session Report
The seventy-second Annual Session of the Arkan-
sas Medical Society Alliance met at the Excelsior Hotel
in Little Rock May 2-4, 1996.
Evelyn Thomas, President, presided over the pre-
convention board meeting and the general sessions of
the House of Delegates. In her closing speech, Mrs.
Thomas related her experience at a medical student
wife member who joined the Auxiliary (Alliance) in
1958. She paid tribute to Mona Lawson whom she
met at a fashion show meeting in Trapnall Hall in 1959.
Mrs. Lawson, who died recently, became Evelyn's
mentor and role model. Evelyn expressed her grati-
tude to her husband, Jerry, and to the members of the
board for their support during the year.
In her report of the year's activities, Mrs. Thomas
cited the emphasis on awareness of domestic violence
and reported on her visits to local chapters. She was
often accompanied by Nancy Hickin, VISTA worker
with the Northeast Arkansas Council on Family Vio-
lence. The two also presented programs to organiza-
tions other than AMSA chapters. Other achievements
Evelyn noted included the increase in membership and
the hiring of a Director of Administrative Services for
the Alliance. She recognized Arleta Power and Mary
Ann Stalling for their roles on the three-year reorgani-
zation team.
During the business sessions, members and del-
egates heard reports from all state officers and from
county and district presidents. Delegates voted to re-
vise the bylaws and constitution to accommodate the
new organizational structure giving the Director of
Administrative Services responsibility for duties for-
merly assigned to the ArkMap editor, publicity chair-
man, corresponding secretary and convention chairman.
After a report from Sebastian County, a special
collection of $250 was taken for victims of the recent
tornadoes there.
In addition to the business sessions, the Annual
Session included receptions for Ruth Mabry, incom-
ing president; and Nancy Russ, Director of Adminis-
trative Services; a silent auction, which was part of the
AMS Wall Street Party; the past presidents' breakfast
and the installation luncheon.
Ruth Mabry Named President
Ruth Mabry of Pine Bluff was elected 1996-97 presi-
dent of the Arkansas Medical Society Alliance at the
Annual Session. Ruth has been a member of the Alli-
ance since 1982. She has served as a member of the
board and president of the Jefferson County Alliance
and as a member of the state board f3r the past four years.
Ruth is a registered nurse and is working toward
a Bachelor of Science in nursing. She works part time
in the office of her husband. Dr. Charles Mabry, who
is a general, thoracic and vascular surgeon. The Mabrys
have three children — David, Scott and Erin.
A member of the Jefferson County Chapter of the
American Red Cross, Emergency Nurses Association,
Volunteers in public schools and Trinity Episcopal
Church, Ruth still finds time to play tennis. She is a
member of the U. S. Tennis Association and is captain
of a 3.0 ladies' tennis team.
Featured Speakers Represent Southern and
National Alliances
Susie Reeder, membership chair of the American
Medical Association Alliance; and Sancy McCool, presi-
dent elect of Southern Medical Association Auxiliary,
were guests speakers at the AMSA.
Reeder discussed the role of the national organi-
zation as a support network that provides "clout"
through numbers for projects and legislation. She
noted the $1.4 million that county and state organiza-
tions contribute to medical education nationwide. The
national group also provides materials and informa-
tion, and opportunities for professional and personal
growth through leadership conferences.
McCool talked about the organization that created
Doctor's Day. March 30 was chosen as the official
date because that's the day the first ether anesthesia
was given; President Bush made the date official in
1990. McCool also noted the organization's five-year
breast cancer awareness project. In addition to other
materials and support for the project. National pro-
vided two billboards for each state.
Mona Lawson Honored at Presidents' Breakfast
Mona Rogers Lawson was honored at the Past
Presidents' breakfast on Friday morning during the
Annual Session. Mona was president of the Arkansas
Medical Society Alliance in 1948-49 and served as presi-
dent of both the Pulaski County Alliance and the na-
tional (American Medical Society) Auxiliary. She held
life memberships in all three organizations. Past presi-
dents and other Alliance members contributed $585 to
the Mona Rogers Lawson Scholarship Fund.
Nineteen past presidents attended the breakfast
hosted by Ginny Blaylock, Carlyn Langston and Mar-
garet Ann Morgan. Mary Ann Stallings, immediate
past president, was initiated.
Volume 93, Number 1 - June 1996
33
Alliance Presidential Address
Ruth Mabry
President 1996-1997
I want to thank all of you for this opportunity to
serve as the President of the Arkansas Medical Society
Alliance. I would like especially to thank my hus-
band, Charles, for his support now and in the year to
come, Evelyn Thomas for her leadership, our special
guests from Southern Medical Association Auxiliary
and American Medical Association Alliance, our 50-
year members and the members here from Jefferson
County.
My goals for the year include more involvement
between county and state levels, an increase in mem-
bership, fundraising to support AMA — ERF, and leg-
islative support. I want to set a membership goal.
Evelyn was able to increase membership this year to a
total of 700 members. I am setting a goal of a previ-
ously set record of 1,000 members at the state level
and encourage all members to join at the national level
as well.
My mterest and enthusiasm come from my involve-
ment over the years at the county level. This is the
"root" of our Alliance. It is at this level that our orga-
nization must grow or we will be unable to exist. The
leadership for projects comes from the national and
state level, but the actual link to patients, providers
and community is at the county level. I plan an orien-
tation session for the county presidents and presidents-
elect in late summer. The Board and membership have
approved sending two more (a total of six) county
members to Leadership Confluence in Chicago this
year. This training is a direct benefit of belonging at
both the state and national level of our organization.
This is definitely the year to be involved in politics
since it is an election year. I hope we will be involved
in issues needing support by the Arkansas Medical
Society.
In closing, I want all of you to know how pleased
and proud I am to represent you as the president of
our Arkansas Medical Society Alliance.
AMSA 1996-1997 Officers
President: Ruth Mabry, Jefferson County
President-elect: Barbara Moody, Member at large
Recording Secretary: Nanette Stroope, Craighead/Poinsett Counties
Treasurer: Liz Pollard, Jefferson County
Vice President Health: Cheryl Pahls, Pulaski County
Vice President, Legislature: Wendy Carlisle, Bowie/Miller Counties
Vice President, Membership: Nancy Ivy, Washington County
Silent Auction Funds Computer
A silent auction held by the AMSA
in conjunction with the AMS Wall
Street Party netted enough money to
buy a computer for the AMSA office.
Items valued at more than $8,000, in-
cluding a $4,000 necklace contributed
by Kahn's Jewelers in Pine Bluff, net-
ted $3,756.50. Every county chapter
supported the auction with donated
items or a cash contribution.
The computer is one more step in
a three year project that resulted in a
restructuring of the board and a grant
from the Medical Society to hire a part-
time Director of Administrative Ser-
vices. The DOAS is available to assist
officers, handle correspondence and
membership renewals and publish the
ArkMap. President Thomas presented
Arleta Power and Mary Ann Stallings
with certificates of appreciation for
their roles in the special project.
34
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Installation luncheon head table.
AMS A President Ruth Mabry with Evelyn Thomas,
Immediate Past President, and Mary Ann Stallings,
Past President.
Mary Ami Stallings, AMSA 1994-1995 President,
is initiated into the Past Presidents' Club.
VISTA Volunteer Nancy Hickin (who works with the NEA
Council on Family Violence) with Evelyn Thomas at
the AMSA exhibitor's booth.
Fifty Year Club
The Fifty Year Club is composed of physicians who, for the past fifty years, have loyally and effectively
served the community and, by skill and devotion to high ideals, upheld and maintained the standards of the
medical profession.
Dr. Ben Saltzman presided over the Fifty Year Club luncheon meeting. Physicians attending the luncheon
were Drs. John Ashley, Max Baldridge, Robert Calcote, Gilbert Campbell, Gilbert Dean, Milton Deneke, Ralph
Downs, Kenneth Duzan, Martin Eisele, C. R. Ellis, George Fotioo, John Guenthner, James Guthrie, James Head-
stream, Fred Henker, Ernest King, Payton Kolb, C. C. Long, Sloan Rainwater, Kenneth Seifert, James Smith,
William Stanton, C. E. Thomas, James Walt, and Morton Wilson.
Freemyer Collection System, Inc.
1-800-694-9288
Collection Services
Electronic Claims
Remittance Posting
Physician Billing
Established 1941
Blytheville *Conway * Helena * Jonesboro * Little Rock * Paragould *West Memphis
36
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
1996 Arkansas Medical Society Shuffield Award
Presented Friday, May 3, 1996
(From left) Rep. Scott Ferguson, M.D., presents the award to Havis Hester
State Rep. Scott Ferguson, M.D., of West Memphis, presented the 1996 Shuffield Award to Havis M.
Hester, Jefferson County Coroner, of Pine Bluff during the 120*’’ Annual Session.
The Shuffield Award is given each year to recognize a non-physician who has made significant contribu-
tions to their community in the area of health care. The award is named in honor of the late Drs. Joe and Elvin
Shuffield, a father and son team from Little Rock, who devoted their lives to the quality of health care in our state.
Hester initiated and continues to maintain the "Check on Your Neighbor" program which raised the
community's consciousness about the risk to elderly individuals whose homes were without air-conditioning.
He also initiated a program entitled, "Shadows of the Medical Field" whereby young high school age students
are brought into the hospital to "shadow" a health professional in their area of interest. The interest and
enthusiasm demonstrated by the young people involved is very inspirational, and a number of them have
been inspired to pursue their education in this area.
Another program Hester has initiated is one for carbon monoxide testing on automobiles and home heat-
ers. He has also provided reflector strips for the handicapped on walkers and wheelchairs. In addition, he has
promoted safety on the highways as well as boating and swimming.
Hester gives a number of educational programs in the area schools, church groups, senior citizen centers
and for law enforcement agencies. He has sponsored a Drug Free Jamboree each year with games and enter-
tainment.
He is a past president of the Intercity Kiwanis and the Arkansas Coroners Association. Other professional
and civic affiliations include the Chamber of Commerce, International Coroners and Medical Examiners Asso-
ciation, National Sheriffs Association, Arkansas Law Enforcement Association, Fraternal Order of Police, Youth
Suicide Prevention Commission, Pines Technical College Advisory Council and Committee, and International
Association of Identification.
Volume 93, Number 1 - June 1996
37
The Golf Tournament
From left: Walter Selakovich, M.D., John Pike, M.D.,
Ramond Read, M.D., and Frank Sipes, M.D.
From left: Paul Meredith, M.D., Bill McGowan, M.D.,
John Crenshaw, M.D., and Charles Logan, M.D.
From left: Asa Crow, M.D., Jerry Mann, M.D., A.E.
Andrews, M.D., and Lynn Zeno.
From left: Don Brandsgaard, exhibitor, Carl Johnson,
M.D., Brad Diner, M.D., and Sha Williamson, exhibitor.
The Winning Team! From left: Jay Radcliff, Joe Mor-
gan, Bob Fewell and Randy Coleman, all represent-
ing American Investors Corporation.
38
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
1996 Grand Prize Winners
Robert L. Baker, M.D.,
of Mountain Home, was
the grand prize winner of a
$1,000 Worldwide Travel
gift certificate for a trip to
the destination of his
choice.
Angie Warren, of
National Park Medical
Center, won the exhibitor
grand prize of $200.
Volume 93, Number 1 - June 1996
39
1996 Annual Session Sponsors
AMS Benefits
Arkansas Blue Cross Blue Shield
Boatmen ’s National Bank of Arkansas
First Commercial Bank
Freemyer Collection System
Healthsouth Rehabilitation Corporation
Jefferson Regional Medical Center
National Park Medical Center
Professional Consulting Services, Inc.
RehabWorks
Roche Laboratories
Schering Corporation
40
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The Doctors ' Company
SEl VING DOCTORS
1£76 -
State Volunteer
Mutual Insurance Company
Southern Medical Association
The Medical Protective Company
The St. Paul Companies
Sponsors not pictured are: American Health Care Providers, Inc. ; Arkansas Regional Organ Recovery Agency (ARORA); Bristol-Myers Squibb;
Eli Lilly and Company; Knoll Pharmaceutical Company; and The Doctors' Company.
Thank You!
1996 Arkansas Medical Society Annual Session Sponsors
The AMS Annual Session would not be possible without the support of our sponsors. The Society
thanks the following for their support of the 120th Annual Session:
American Health Care Providers, Inc. (Early Morning Refreshments)
American Investors Life Insurance Company (Hospitality Hour)
AMS Benefits (Inaugural Banquet and Sport Shirts)
Arkansas Blue Cross Blue Shield (Wall Street Party)
Arkansas Regional Organ Recovery Agency (ARORA) (Golf Tournament Refreshments & Prizes)
Boatmen's National Bank of Arkansas (Welcome Reception)
Bristol-Myers Squibb (Educational Grant)
Eli Lilly and Company (Educational Grant)
First Commercial Bank (Continental Breakfast)
Freemyer Collection System (Educational Grant)
Healthsouth Rehabilitation Corporation (Golf Refreshments & Prizes)
Jefferson Regional Medical Center (President's Reception & Dance)
Knoll Pharmaceutical Company (Afternoon Break)
National Park Medical Center (Afternoon Break)
Professional Consulting Services, Inc. (Young Physicians Seminar)
RehabWorks (Program Back Cover)
Roche Laboratories (Educational Grant)
Sobering Corporation (Golf Tournament Refreshments & Prizes)
Southern Medical Association (Wall Street Party)
State Volunteer Mutual Insurance Company (Physician Grand Prize)
The Doctors' Company (President's Reception & Dance)
The Medical Protective Company (Session Portfolios)
The St. Paul Companies (Educational Grant)
1996 Annual Session Exhibitors
Thank you for being a
part of our 1996 convention!
Abbott Laboratories
Myers, Loveless, Brandsgaard, Inc.
American Physicians Insurance Exchange
National Medical Systems
AMS Benefits, Inc.
National Park Medical Center
Arkansas Army National Guard Medical Recruiting
Olsten Kimberly Quality Care
Arkansas Blue Cross Blue Shield
Paul Revere Life Insurance Company
Arkansas Foundation for Medical Care
Pfizer Pharmaceuticals
Arkansas Medicaid Deferred Compensation Program
Pratt Pharmaceuticals, Pfizer, Inc.
Autoflex Leasing
Procter & Gamble Pharmaceuticals
Baptist Health Information Network & Practice Plus
Professional Consulting Services, Inc.
Baptist Medical Center
Rebsamen Regional Medical Center
Bayer Corporation
RehabCare Group
Becker, Inc. - Prodenco
RehabWorks
Boatmen’s Trust Company
Roche Laboratories
Columbia Health System of Arkansas
Rhone-Poulenc Rorer
Computer Literacy of Arkansas
Schering Corporation
ConsumerQuote USA
Sobering Oncology/Biotech
Dean Witter Reynolds
SmithKline Beecham Clinical Laboratories
Dial-a-Page
Snell Prosthetic & Orthotic Laboratory
Disability Determination for Social Security
Southern Medical Association
Fendley’s Fine Jewelry & Unique Gifts
St. Vincent Infirmary Medical Center
First Commercial Bank
St. Vincent Infirmary Medical Center-PET
Freemyer Collection System
State Volunteer Mutual Insurance Company
G.D. Searle & Co.
Tap Pharmaceuticals, Inc.
Genentech, Inc.
Taylor Home Health Supply
Geriatric Mental Health Services
The Armstrong Team
Healthsouth Rehabilitation Corporation
The Medical Protective Company
Horizon - CMS
The St. Paul Companies
Hot Springs Rehabilitation Center
Timber Ridge Group, Inc.
Janssen Pharmaceutica
UAMS Library
Jefferson Regional Medical Center
UAMS Medical Center
Key Pharmaceuticals
U.S. Air Force Health Professions
Medical Office Management Systems, Inc.
U.S. Air Force Reserves
MediCom, Inc.
U.S. Army Health Care Recruiting
Mercantile Bank
Venisect, Inc.
Merck & Co.
Annual Session Pics
Photo to the left: Our photographer
catches Gilbert O. Dean, M.D., of
Little Rock as he sits in the red
Mercedes brought for display in the
exhibit hall by Autoflex Leasing.
Two photos above: A crowd gathers around
as members of the Metropolitan Junior
Chamber of Commerce update and forecast
the market during the Wall Street Game.
Photo to the left: Asa Crow, M.D., and A.E.
Andrews, M.D., at the Wall Street Party.
Photo to the right: Immediate Past President
James Armstrong, M.D., talks with Charles
Logan, M.Do, and Jerry Mann, M.D.
More Annual Session Pics
Photo to the left: Vice President James
Crider and his wife.
Photo below: J. Larry Lawson, M.D.,
and his wife, Nikki, tear up the dance
floor on this number at the President's
Reception and Dance.
Photo above: President John
Crenshaw, M.D.
Photo to the right: Everyone dances
the night away at the President's
Reception and Dance.
In Memoriam
The following members of the Arkansas Medical Society and Arkansas Medical Society Alliance
were remembered during the 1996 AMS Annual Session.
Society Members:
E. Clinton Texter, Little Rock
Walter P. Harris, Danville
Henry N. Rogers, Mena
Lelon J. Bull, Yucaipa, California
R. Frank Rhodes, Osceola
Douglas W. Parker, Van Buren
Vida H. Gordon, Little Rock
Francis E. Shearer, Alma
Joseph F. Gartman, Carlisle
Caswell M. Kirkman, Helena
Charles A. Archer, Conway
Lucille K. Champion, North Little Rock
J. Arnold Henry, Russellville
William K. Jordan, Pine Bluff
John C. Winters, Desha
Debra L. Owings, Little Rock
H. Thurston Black, Little Rock
William G. Lockhart, Fort Smith
William A. Runyan, Little Rock
Glen P. Schoettle, West Memphis
Norman Hill, Lake Village
C. Lynn Harris, Hope
Hayden Nicholson, Santa Clara, California
Robert W. Ross, Conway
James C. Barnett, Heber Springs
J.W. Carney, Newport
Kingsley W. Cosgrove Jr., Little Rock
Leston E. Fitch, Conway
Charles R. Winn, Little Rock
Alliance Members and Spouses:
Mrs. Neil E. Crow, Sr., (Mary K.) Fort Smith
Mrs. Waldo Regnier (Mary E.), Crossett
Mrs. George W. Jackson (Mary G.), Hot Springs
Mrs. Martin E. Blanton (Sallie Mae), Jonesboro
Mrs. Russell Gobb (Mary), Malvern
Mrs. E. J. Ritchie (Leona), North Little Rock
Mrs. Charles D. Cyphers (Margaret), El Dorado
Mrs. Gaston A. Hebert (Velda), Hot Springs
Mrs. Mason G. Lawson (Mona), Little Rock
Volume 93, Number 1 - June 1996
45
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Cardiology Commentary and Update
Mindy D. Boyles, R.N.*
J. David Talley, M.D.**
GLOVES: FRIEND OR FOE?
The fear of contacting an infectious agent has in-
creased the use of gloves (Figure 1), both sterile and
unsterile, latex and rubber, in the patient-care envi-
ronment. At present, the University Hospital of Ar-
kansas uses nearly 225,000 pairs of sterile gloves, and
more than 2,225,000 pairs of non-sterile gloves annu-
ally. This expanded practice is associated with an con-
comitant concern regarding the reports of glove-related
allergic reactions and the degree of safety that gloves
provide against infectious agents. This review will dis-
cuss recent information on glove technology.
Patient Presentation
A 26-year-old registered nurse worked in a coro-
nary care unit in a tertiary care hospital. She devel-
oped an erythematous, eczematous rash on the dorsal
aspects of her hands extending to the wrist within
several days after wearing latex gloves. She had no
systemic hypersensitivity reactions including shortness
of air, angioedema, or pruitis. She was extremely sen-
sitive to kiwi fruit; merely tasting the fruit caused se-
vere swelling of the oral mucosal membranes. She had
no other allergies. The use of low-allergen,
non-powdered gloves decreased the occurrence of this
presumptive local, type IV delayed hypersensitivity
reaction to latex.
Discussion
Latex, also known as natural rubber latex, is a pro-
cessed plant product, derived from the milky sap of
the rubber tree, Hevea brasiliertsis. It was brought from
South American to Europe in the mid-18th century.
Joseph Priestley named it rubber in 1770 when he disco v-
* J. David Talley, M.D., is affiliated with the Division of
Cardiology at UAMS Medical Center.
** Mindy D. Boyles, R.N., is affiliated with the Division of
Cardiology at UAMS Medical Center.
ered it could rub away pencil marks. In 1818, James
Syme used it to waterproof cloth for raincoats; five
years later Charles Macintosh patented the process.
In 1839, Charles Goodyear discovered the process of
vulcanization-adding sulfur to heated rubber-which
produced a more flexible, elastic and durable material.’
Localized reactions to latex gloves Local reactions
to latex have been reported since the first part of the
20th century. These T-cell mediated reactions produce
local effects including erythema and edema within
hours to a few days after wearing the gloves. The al-
lergen may be one of several compounds in the glove,
including soluble proteins in the latex itself, chemicals
added in the preparation of the glove, or starch pow-
der which is used as a lubricant in the inside of the
glove. ^ The incidence of local reactions is rising, and is
now estimated to occur in 5 to 10% of health care pro-
viders. Patients with spine bifida have a high incidence
of latex allergy which may be related to heightened
sensitization from frequent exposure to urinary cath-
eters and sterile gloves or a genetic abnormality in the
immune system.^ An association with an allergy to
kiwi, avocado, banana, or chestnut has also been re-
ported.’
Systemic reactions to latex gloves Systemic reac-
tions to latex are immediate, antigen-antibody (IgE)
mediated, and maybe be life threatening. Exposure to
the antigen maybe either by cutaneous, mucosal, or
parenteral routes. Cutaneous exposure results in con-
tract urticaria, angioedema, or pruitis. Exposure of the
respiratory or parenteral mucosa may cause rhinitis,
asthma, or anaphylaxis. Erequent occupational expo-
sure may increase the sensitivity to latex. Latex sensi-
tization may be detected with the skin prick test.'* Use
of hypoallergenic gloves (either with minimal or no
powder) decreases the occurrence of the systemic re-
actions (Table 1).^
Volume 93, Number 1 - June 1996
47
Figure 1: The fear of contracting an infectious agent has
increased the use of gloves, both sterile and unsterile, la-
tex and rubber, in the patient-care environment.
Gloves as a barrier Do gloves provide a protective
barrier from infectious agents? Korniewicz and col-
leagues noted that vinyl gloves were associated with
nearly a five-fold increase in perforation and leakage
as compared to latex gloves (vinyl: 85% vs. Latex: 18%).^
Not all latex gloves are the same; the same study noted
a three-fold increase in the perforation rate between
private and commercial brands of the gloves. The prac-
tice of "double-gloving" decreases the perforation rate
of vinyl gloves but provides no additional protection
when latex gloves are used.’’ Gloves used during surgi-
cal procedures are more prone to leak than those used
in diagnostic procedures.** It is reported that latex gloves
may provide better protection against human immu-
nodeficiency virus than other glove types.®
Conclusions
Health-care providers are at an increasing occupa-
tional risk of an allergic reactions to latex gloves.
Hypoallergenic, non-powered gloves decreases the risk
of local and systemic immunological reachons. The best
barrier against infection is the use of high-quality latex
gloves. Frequently changing gloves during prolonged
or therapeutic procedures guards against microscopic
perorations.
References:
1. Isaacs BS. Allergic to Latex?? It's no joke? Louisville Med
1996;43;500-501 .
2. Beezhold D, Beck WC. Surgical glove powders bind latex
antigens. Arch Surg 1992;127:1354-1357.
3. D'Astous J, Drouin MA, Rhine E. Intraoperative anaphy-
laxis secondary to allergy to latex in children who have spine
bifida. Report of two cases. J Bone Joint Surg
1992;74:1084-1086.
4. Arellano R, Bradley J, Sussman G. Prevalence of latex
sensitization among hospital physicians occupationally ex-
posed to latex gloves. Anesthesiology 1992;77:905-908.
5. Vandenplas 0, Delwiche JP, Depelchin S, Sibille Y, Vande
weyer R, Delaunois L. Latex gloves with a lower protein
content reduce bronchial reactions in subjects with occupa-
tional asthma caused by latex. Am J Resp Grit Care Med
1995;151:887-891.
6. Korniewicz DM, Kirwin M, Cresci K, Larson E. Leakage
of latex and vinyl exam gloves in high and low risk clinical
settings. Am Industrial Hygiene Assoc J 1993;54:22-26.
7. Korniewicz DM, Kirwin M, Cresci K, Sing T, Choo TE,
Wool M, Larson E. Barrier protection with examination
gloves: double versus single. Am J Infect Cont 1994;22:12-15.
8. Baggett FJ, Buirke FJ, Wilson NH. An assessment of the
incidence of puncture in gloves when worn for routine op-
erative procedures. Br Dent J 1993;174;412-416.
9. Heller ET, Greer CR. Glove safety: Summary of recent
findings and recommendations from health care regulators.
South Med J 11995;88: 1093-1 098.
Table 1
Categories of Gloves
Sterile latex
gloves
Hypoallergenic
latex sterile
gloves
Non-Powder
non-steiile latex
gloves
Regular
non-sterile gloves
Baxter,
Triflex
Ansell Perry,
DermaPrene
Ansell Perry,
Dermaclean-
Conform
Ansell Perry,
Conform-latex
Professional
Medical Products,
Brown Milled
Baxter,
Triflex Orthopedic
Baxter,
Ultraderm
Becton-Dickinson-
vinyl
Manufacturers:
Ansell Perry Inc., Massillon, Ohio
Baxter Healthcare Corporation, Grand Prairie, Texas
Becton-Dickinson, Sparks, Maryland
Professional Medical Products, Irving, Texas
48
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
I#
StAtc HeaJtb WMcl
Information provided by the Arkansas Department of Health, Division of Epidemiology
Tick, Tock, Tick, Tock: Have You Seen Any Freckles with Legs Recently?
Tickborne diseases are a continuing threat to health
in Arkansas, and a diagnostic dilemma for physicians.
There are four tickborne diseases recognized as being
more or less common in the state, with many cases
presenting as fevers of unknown origin. (See Figure 1
for the distribution of reports in Arkansas.) Lyme
disease is reported rarely in Arkansas, Rocky Moun-
tain Spotted Fever (RMSF) and tularemia are relatively
common, and ehrlichiosis is an emerging infectious
disease. (See Figure 2.) Ehrlichia case reporting has
only recently been made mandatory in Arkansas, and
29 cases were reported during 1991-1995.
Lyme disease is currently the most frequently re-
ported tickborne disease in the U.S. In 1994, 43 states
reported 13,043 cases. Seven states, Mississippi, Ha-
waii, Alaska, Montana, Arizona, North Dakota, and
South Dakota reported no cases; 13 states and Wash-
ington D.C. reported 1-10 cases, 14 reported 15-100,
and 13 reported 101-500. New York, Connecticut, New
Jersey, and Pennsylvania reported over 1,000 cases.
The highest rate was reported from Connecticut, 2.030
cases (62 per 100,000). Other rates ranged from 47 in
Rhode Island (471 cases) and New York (5,200 cases),
to Wisconsin (8) and Minnesota (4.6). Although Okla-
homa reported 99 cases (rate==3.0) and Missouri re-
ported 102 (1.9), other surrounding states reported
lower rates than Arkansas (0.6). The U. S. rate for
1994 was 3.8 per 100,000 persons.
Lyme disease is less likely to be reported in chil-
dren in Arkansas than in states where the disease is
more common. (See Figure 3.) It is noteworthy that
the highest number of Lyme cases are reported in the
20-29 and 70-79 age groups. This is in distinction to
tularemia and RMSF, which show generally decreas-
ing rates with advancing age. An exception to this is
the higher rate in males in the 30-39 group, which
probably reflects increased outdoor activities and con-
sequent tick exposure.
Diagnosis of Lyme disease is problematic in states
such as Arkansas where the disease is uncommon.
Serologic tests are of low predictive value and are es-
pecially insensitive in early stages of the disease. Cross-
reacting antibodies may cause false-positive reactions
Figure 1. Reported Cases of Tickborne Diseases
in Arkansas, 1991 - 1995*
Figure 2. Tickborne Diseases in
Year
1991
1992
1993
1994
1995
Lyme —
31
20
8
15
11
RMSF
36
24
17
18
31
Tula
48
39
36
23
22
Total - -
115
83
61
56
64
Volume 93, Number 1 - June 1996
49
Figure 3. Tickborne Diseases in
Arkansas, 1991-1995
By Age of Patient
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80--I-
Age Group
^LYME ^RMSF E]TULA
Figure 4. Arkansas Tickborne Diseases
By Month of Occurrence
1991-1995
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Month
LYME RMSF TULA TOTAL
in patients with syphilis, relapsing fever, leptospiro-
sis, HIV infection, RMSF, infectious mononucleosis,
lupus or rheumatoid arthrihs. Diagnosis should largely
be based on clinical findings, with support by ELISA
and immunoblotting techniques. The characteristic
skin lesion. Erythema Migrans, must reach 5 cm. in
diameter for case surveillance purposes. Early sys-
temic symptoms may include malaise, fatigue, fever,
headache, stiff neck, myalgia, migratory arthralgias
and/or lymphadenopathy, possibly lasting several
weeks or more in untreated patients. Later systemic
manifestations may include neurologic and cardiac
abnormalities, and episodic or chronic arthritis.
RMSE remains the most potentially serious of the
group, with a 5% overall fatality rate. With prompt
recognition and treatment, RMSF deaths are uncom-
mon. Risk factors associated with more severe dis-
ease and death include delayed antibiotic therapy and
patient age over 40 years. Absence or delayed appear-
ance of the typical rash contributes to delay in diagno-
sis and increased fatality. RMSF caused 6 deaths dur-
ing 1991-1995.
RMSF is marked by sudden onset of moderate to
high fever, malaise, deep muscle pain, severe head-
ache, chills and conjunctival injection. In about half
the cases, a maculopapular rash appears on the ex-
tremities on about the third day; this soon includes
the palms and soles and spreads rapidly too much of
the body. Petechiae and hemorrhages are common.
Early RMSF may be confused with ehrlichiosis, men-
ingococcemia, and enteroviral infection.
Arkansas continues to report a disproportionate
number of tularemia cases. During 1991-1995, 168 (24%)
of the U.S. total 700 tularemia cases were reported in
Arkansas. Of the 168, 32 (19%) were in the 0-9 year
age group. (See Figure 3.) The ulceroglandular form
of the disease is most common in Arkansas. Three
fatalities were attributed to tularemia in 1991-1995.
The emerging disease, ehrlichiosis, is being recog-
nized and reported more frequently. In Arkansas, the
14 cases reported in 1995 nearly equaled the total (15)
reported in the four previous years. Although there is
no national reporting requirement, more than 400 cases
of monocytic ehrlichiosis (the variant recognized in
1986) and approximately 170 cases of human granulo-
cytic ehrlichiosis (HGE, first seen in 1990) have been
reported. The agent of monocytic ehrlichiosis is
Ehrlichia chaffeensis, and the taxonomic status of the
HGE agent is yet to be determined. By rDNA testing,
it has been placed closely to E. eqiii and £.
phagocytophilia, previously recognized animal patho-
gens. Both forms of ehrlichiosis may interfere with
certain immune responses. Opportunistic infections
have been observed in serious cases, although the
mechanisms of possible immune interference are not
known as yet.
The probability of tickborne disease is relatively
high in Arkansas, and the summer months in Arkan-
sas bring more opportunities for human exposure to
ticks and the possibility of tickborne disease (Eigure
4.). The Arkansas Department of Health (ADH) en-
courages physicians to make use of laboratory tests to
diagnose patients with possible cases. The ADH Labo-
ratory offers the immunofluorescent antibody test for
RMSF and serologic test for tularemia, and also refers
specimens to laboratories at the Centers for Disease
Control and Prevention for Lyme disease and
ehrlichiosis. Paired acute and convalescent specimens
are recommended; often, a single specimen yields a
result which does not prove a diagnosis. Specimens
should be obtained two to three weeks apart.
50
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reported Cases of Selected Reportable Diseases in Arkansas
Profile for March 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was
reported.
Selected
Reportable
Diseases
Total
Reported
Cases
March 1996
Total
Reported
Cases
YTD1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1995
Total
Reported
Cases
1994
Campylobacteriosis
8
30
30
20
152
187
Giardiasis
10
29
29
21
131
126
Shigellosis
9
13
28
38
175
193
Salmonellosis
15
49
36
38
332
534
Hepatitis A
36
149
59
22
663
253
Hepatitis B
9
25
19
14
92
60
HIB
0
0
4
1
6
5
Meningococcal Infections
0
15
15
23
39
55
Viral Meningitis
0
7
2
8
31
62
Lyme Disease
1
3
2
5
9
15
Rocky Mountain Spotted Fever
0
0
0
3
30
18
Tularemia
1
1
1
4
22
23
Measles
0
3
2
1
2
5
Mumps
0
0
3
2
5
7
Rubella
0
1
0
0
0
0
Gonorrhea
375
1211
979
1769
5437
7078
Syphilis
95
235
240
274
1017
1096
Legionellosis
0
0
2
4
5
16
Pertussis
0
3
9
10
60
33
Tuberculosis
16
32
41
33
271
264
Volume 93, Number 1 - June 1996
51
Arkansas HIV/ AIDS Report
1983-1996
HIV In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Repwiting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include;
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501) 661-2387.
NOTE: Qjunty of residence may
change from date of HIV test to date
of AIDS diagnosis.
HIV+ CASES
REPORTED
□
1 to 3
□
4 to 49
50 to 99
■
100 to 1251
I County of residence at the time of test for the 3,545 Arkansans reported to be HIV+. (4/12/96)1
HIV
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
1
Male
100
215
248
413
400
392
352
367
337
109
2,933
83
X
Female
8
26
37
68
85
81
94
90
92
31
612
17
Under 5
1
1
2
8
13
6
3
7
2
0
43
1
5-12
0
1
1
5
1
2
1
0
1
0
12
0
13-19
0
7
8
14
19
25
11
22
12
12
-130
4
20-24
12
40
52
71
44
49
64
60
11147;
13
452;
13
25-29
21
70
71
112
105
107
111
85
78
31
791
22
A
30-34
25
50
64
116
120
111
91
102
101
23
803
23
G
35-39
19
36
40
80
88
68
77
69
81
28
586
17
E
40-44
16
17
17
43
50
41
47
50
46
11
338
10
45-49
6
8
18
13
20
26
18
27
24
5
165
5
50-54
2
1
5
8
14
14
10
12
. 17
7
90
3
55-59
1
3
4
6
3
13
6
7
5
6
54
2
60-64
1
0
1
1
2
6
5
9
8
1
34
1
65 and older
4
2
1
2
3
5
2
7
7
3
. 36
1
R
White
87
170
174
328
298
293
278
259
260
72
2,219
63
A
Black
21
69
108
151
"184
173
163
184
159 -
61
1,273
36
C
Hispanic
0
1
3
1
3
4
1
7
3
2
25
1
E
Other/Unknown
0
1
0
1
0
3
4
7
7
5
28
1
Male/Male Sex
64
137
140
243
246
260
242
229
156
38
1,755
50
Injection Drug User (IDU)
13
30
48
74
96
75
65
71
48
6
526
15
R
Male/Male Sex & IDU
19
23
24
32
30
34
26
23
■25
8
244
7
1
Heterosexual (Known Risk)
5
25
26
59
64
68
100
93
56
14
510
14
S
Transfusion
5
5
4
6
8
10
0
2
2
0
42
1
K
Perinatal
1
2
8
‘ 13
8
4
7
0
0
44
1
Hemophiliac
0
0
6
18
5
6
2
3
5»
0
45
1
Undetermined
1
20
35
41
23
12
7
29
137
74
379
11
HIV CASES BY YEAR
108
241
285
481
485
473
446
457
429
140
3,545
100
Arkansas Department of Health HIV/AIDS Surveillance Program
52
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1996
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: County of residence may
change from date of HI V test to date
of AIDS diagnosis.
AIDS
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
1
Male
85
77
70
170
176
250
334
253
238
76
1,729
87
X
Female
. :;5
6
10
20
25
35
64
42
36
16
259
13
Under 5
0
1
1
6
6
3
2
1
2
0
22
1
5-12
0
1
0
1
1
0
' 1
0
2
0
6
0
13-19
0
0
0
4
3
2
4
3
1
0
17
1
20-24
7
5
11
11
14
14
31
22
11
4
130
7
25-29
24
22
13
44
43
67
78
45
47
13
396
20
A
30-34
20
21
21
47
42
73
98
81
75
28
506
25
G
35-39
19
15
20
31
38
55
80
52
49
20
379
19
E
40-44
10
7
4
21
35
28
49
39
35
14
242
12
45-49
5
3
3
14
6
24
28
22
17
4
126
6
50-54
1
1
2
5
6
7
10
12
15
2
61
3
55-59
2
2
4
1
4"
8
8
5
■ 6
4
44
2
60-64
1
1
1
1
1
2
6
10
5
0
28
1
65 and older
1
4
0
4
2
2
3
3
9
3
31
2
R
White
74
61
58
141
134
206
273
190
174
55
1,366
69
A
Black
16
20
21
47
66
75
121
102
97
35
600
30
C
Hispanic
0
1
0
0
1
3
3
2
3
2
15
1
E.
Other/Unknown
0
1
1
2
0
1
1
1
0
0
7
0
Male/Male Sex
55
59
50
122
120
183
237
165
132
35
1,158
58
Injection Drug User (IDU)
12
4
11
18
29
45
70
46
45
4
284
14
R
Male/Male Sex & IDU
16
6
6
18
' 17
21
27
23
20
7
161
8
1
Heterosexual (Known Risk)
' 5
3
7
11
12
24
52
41
32
5
192
10
S
Transfusion
2
7
3
7
11
3
2
4
3
1
43
2
K
Perinatal
0
1
1
6
6
3
3
1
3
0
24
1
Hemophiliac
0
1
5
5
4
5
6
7
1
35
2
Undetermined
0
2
1
3
1
2
2
9
32
39
91
5
AIDS CASES BY YEAR
90
83
80
190
201
285
398
295
274
92
1,988
100
Arkansas Department of Health HIV/AIDS Surveillance Program
AIDS In
Arkansas
I Of the 3,545 Arkansans reported to be HIV+, 1,988 have been diagnosed with AIDS. (4/12/96)1
Volume 93, Number 1 - June 1996
53
New Members
DERMOTT
Zangari, Maurizio, Internal Medicine/Hematology.
Medical Education, University Padova Italy, 1980. Resi-
dency, Wyckoff Medical Center, New York, 1990. Board
certified.
EUDORA
Gregory, Jo Anne, Family Practice. Medical Edu-
cation, Meharry Medical College, Nashville, Tennes-
see, 1992. Residency, UAH Family Practice, Hunts-
ville, Alabama, 1995. Board certified.
HARRISON
Clary, Cathy J., Family Practice. Medical Educa-
tion, UAMS, 1993. Internship/Residency, AHEC North-
west, 1994/1996.
HOT SPRINGS
Vasudevan, Padmini, Neurology. Medical Educa-
tion, University of Delhi, India, 1972. Internship/Resi-
dency, M.A. Medical College & Associated Hospital,
1971/1975.
LITTLE ROCK
Andrews, Nancy Rai, Obstetrics & Gynecology.
Medical Education, Meharry Medical College, Nash-
ville, Tennessee, 1990. Internship, Meharry Medical
College, 1990. Residency, University of Arkansas, 1994.
Christy, George William, Cardiovascular Diseases.
Medical Education, Loyola University Stritch School
of Medicine, Maywood, Illinois, 1985. Internship,
Emory University School of Medicine, 1986. Residency,
Emory University Hospital, 1988. Board certified.
Fitzgerald, Amy J., Internal Medicine. Medical
Education, Louisiana State University School of Medi-
cine, Shreveport, 1992. Internship, Louisiana State
University Medical Center, 1993. Residency, UAMS,
1995. Board certified.
POCAHONTAS
Landis, Mark A., Family Practice. Medical Edu-
cation, East Tennessee State University, Johnson City,
1994. Residency, AHEC Northeast, 1994. Board certified.
OUT OF STATE
Meredith, Paul Drew, General Practice. Medical
Education, UAMS, 1973. Internship/Residency, UAMS,
1974/1976. Board certified.
RESIDENTS
Baho, Najla J. Medical Education, University of
Aleppo, Syria, 1990.
54
Bean, Paul Edward, Internal Medicine. Medical
Educahon, UAMS, 1996. Internship/Residency, UAMS.
Brown, Robert D., Medical Education, UAMS, 1992.
Burke, Charles Thomas, Medical Education,
UAMS, 1996. Internship, UAMS.
Calhoun, Aris Jeannette, Family Medicine. Medi-
cal Educahon, UAMS, 1996. Internship, Louisiana State
University, Shreveport.
Clark, Teresa M., Emergency Medicine. Medical
Education, UAMS, 1996. Internship/Residency, UAMS.
Dickson, Brian Glenn, Medical Education, UAMS,
1996. Internship, UAMS, 1997.
Dugger, Joseph Scott, Family Practice. Medical
Educahon, UAMS, 1996. Internship/Residency, AHEC
Northeast.
Elliot, Jana Crain, Internal Medicine/Pediatrics.
Medical Educahon, UAMS, 1996. Internship/Residency,
UAMS.
Hart, Susan K., Family Practice. Medical Educa-
hon, UAMS, 1996. Intemship/Residency, AHEC Northwest.
Houston, Melinda Lee, Pediatrics. Medical Edu-
cation, UAMS, 1996. Internship, UAMS.
Jetton, Christirla Ann, Radiology. Medical Edu-
cation, UAMS, 1996. Residency, UAMS.
Lowery, Lisa Ann, Internal Medicine. Medical
Education, UAMS, 1996. Residency, UAMS.
Lucas, Shauna Lee, Family Practice. Medical Edu-
cation, UAMS, 1996. Residency, AHEC Fort Smith.
McKelvey, Kent D., Family Medicine. Medical
Educahon, UAMS, 1996. Internship/Residency, AHEC
Southwest.
Merchant, Rhonda J., Pediatrics. Medical Educa-
tion, UAMS, 1996. Residency, UAMS.
Russell, Shelley White, Internal Medicine/Derma-
tology. Medical Education, UAMS, 1996. Internship/
Residency, UAMS.
Shoppach, Jon Paul, Radiology. Medical Educa-
tion, UAMS, 1996. Residency, UAMS.
Slay, David R., Medical Education, UAMS, 1996.
Internship, UAMS.
Stewart, Jason Garner, Orthopedic Surgery. Medi-
cal Educahon, UAMS, 1996. Intemship/Residency, UAMS.
Tharp, Paul S., Medical Education, UAMS, 1996.
Internship, UAMS. Residency, Stanford, Palo Alto,
California.
Thrasher, James Randall, Internal Medicine. Medi-
cal Education, UAMS, 1996. Residency, UAMS.
Webber, John Charles, Psychiatry. Medical Edu-
cation, UAMS, 1996. Residency, UAMS.
Whiteside, Thomas Fletcher, Pathology. Medical
Education, UAMS, 1996. Internship, UAMS.
Zelk, Misty Michelle, Medical Education, UAMS,
1996. Residency, UAMS.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
Joseph S. Murphy, M.D.
Steven R. Nokes, M.D.
History:
A 45-year-old female was referred for a stereotactic needle biopsy of a mass seen in the medial aspect of the
right breast seen only on the craniocaudal view (arrow in figure 1). What is the most likely diagnosis?
Figure 1A and 1B: Mediolateral (top) and craniocaudal (bottom) mammograms.
Volume 93, Number 1 - June 1996
55
Sternalis Muscle
Diagnosis:
Sternalis muscle.
Radiographic Findings:
On the craniocaudal view a 1.5 cm density is seen far medially. A CT scan was performed (figure 2) which
reveals an asymmetric sternalis muscle (arrow) separated by fat from the pectoralis major muscle.
Figure 2: Axial CT scan of the chest.
Discussion:
The sternalis muscle is an anatomic variant that occurs in approximately 8% of both men and women and is often
unilateral. It runs longitudinally along the medial border of the sternum and is of uncertain teleology and function. A fat
plane separates it from the pectoralis major muscle.
Recent efforts to improve mammography by the American College of Radiology have led to improved positioning
and inclusion of more breast tissue, particularly posterior and medial on the craniocaudal view. With proper elevation
of the inframammary fold, the pectoralis major muscle should be seen on approximately 30% of craniocaudal images.
This technique will also increase visualization of the sternalis muscle.
It is important to recognize this inconstant benign variant, most often seen on craniocaudal mammograms, to
avoid an unnecessary recall, follow-up exam or biopsy.
References:
1. Bradley FM, Hoover HC, Hulka CA, et al. The sternalis muscle: an unusual normal finding seen on mammography. AJR 1996,
166:33-36.
2. American College of Radiology. Mammography quality control manuals. Reston, VA: American College of Radiology, 1994.
3. Ekiund GW, Cardenoza GC. The art of mammographic positioning. Radiol Clin North AM 1992;30:21-53.
Authors:
Editor: Steven R. Nokes, M.D. is associated with Radiology Consultants in Little Rock.
Contributor: Joseph S. Murphy, M.D. is associated with Radiology Consultants in Little Rock.
56
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Things To Come
September 6-7
3rd Annual Current Topics in Cardiothoracic
Anesthesia. Washington University Medical Center,
St. Louis, Missouri. Sponsored by the Office of Con-
tinuing Medical Education, Washington Univ. School
of Medicine. For more information, call 1-800-325-9862.
October 9-13
Infectious Disease '96 Board Review Course - A
Comprehensive Review for Board Preparation. The
Hyatt Regency Hotel, Washington, D.C. Sponsored
by the Center for Bio-Medical Communication. For
more information, call (201) 385-8080.
October 17 - 19
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
November 1-3
New Developments in the Pathogenesis & Treat-
ment of NIDDM (non-insulin dependent diabetes
mellitus). Radisson Resort, Scottsdale, Arizona. Spon-
sored by the American Diabetes Association of Ari-
zona and the National Institute of Diabetes and Di-
gestive and Kidney Diseases. For more information,
call (602) 995-1515.
November 20 - 24
90th Annual Scientific Assembly - Yesterday's
Caring with Today’s Technology. Baltimore Conven-
tion Center, Baltimore, Maryland. Sponsored by the
Southern Medical Association. For more information,
call (800) 423-4992 or (205) 945-1840.
December 7
Cardiology Seminar. Washington University Medi-
cal Center, St. Louis, Missouri. Sponsored by the Of-
fice of Continuing Medical Education, Washington Uni-
versity School of Medicine. For more information, call
1-800-325-9862.
BE AN AIR FORCE
PHYSICIAN.
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want to be while serving your country in
today’s Air Force. Discover the tremen-
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to an Air Force medical program manag-
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Today’s Air Force offers the medical envi-
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fy. Call HEALTH PROFESSIONS
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Volume 93, Number 1 - June 1996
57
We can't guarantee that they'll follow in your footsteps, but we do know they need good health insurance
today. And so do you.
FINALLY, a health insurance plan designed to meet the needs of Arkansas' physicians. The ARKANSAS
MEDICAL SOCIETY HEALTH BENEFIT PROGRAM... offering a variety of benefit options including a choice
between basic indemnity and managed care. For information call (501) 224-8967 or 1-800-542-1058.
Arkansas Medical Society
Health
Underwritten by
American Investors
Life Insurance Company
Benefit Program
In cooperation with
Arkansas Managed
Care Organization
Exclusively for members of the Arkansas Medical Society. Developed by AMS BENEFITS, INC. in conjunction with American
Investors Life and Arkansas Managed Care Organization.
AMS BENEFITS, INC
A wholly owned subsidiary of the Arkansas Medical Society
P. O. Box 5776, Little Rock, Arkansas 72215-5776 • (501) 224-8967 • WATS 1-800-542-1058 •
FA7a50d^22^i^489
Keeping Up
Recurring Education Programs
The following organizations are accredited hy the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category I of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/ General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Spine Center Conference, 1st Wednesday, 7:00 a.m.. Southwestern Bell/Arkla Room. Light Breakfast provided.
Urology Grand Rounds, September 17th and November 5th, 5:30 p.m.. Southwestern Bell/Arkla Room, Refreshments provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
As an organization accredited for continuing medical education by the Accreditation Council for Continuing Medical Education, the
University of Arkansas for Medical Sciences certifies the following continuing medical education activities meet the criteria for Category I
of the Physician's Recognition Award of the American Medical Association.
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Oncology Forum, Thursdays, 4:00 p.m., UAMS ACRC 2nd Floor Board room, 1.5 credits
Anesthesia Lecture Series, Wednesdays, 4:00 p.m., UAMS Education Bldg., room G/110 A&B
Anesthesia Morbidity & Mortality Conference, Tuesdays, 6:45 a.m.; 2nd & 4th Thursdays, 4:00 p.m., UAMS Education Bldg.,
room G/110 A&B
Volume 93, Number 1 - June 1996
59
Cardiology Graphics Conference, Tuesdays, 12:00 noon, VAMC, room 5C114
CARTI North Tumor Board Cancer Conference, 2nd Wednesday, 12:00 noon, CARTI North, Searcy
Cardiothoracic Surgery Conference, date, time, & location varies
Cardiothoracic Surgery Monthly Journals Club, 4th Saturday, 9:30 a.m., UAMS Surgery Dept. Library, room 2S/28D
Cardiothoracic Surgery Morbidity & Mortality Conference, 2nd Saturday, 9:30 a.m., UAMS Surgery Dept. Library, room 2S/28D
Child Psychiatry Update/Case Conference, 3 Fridays per month, 1:00 p.m., ACH Child Study Center conference room
CME Outreach Program, dates, times & locations vary
EKG Conference, Mondays, noon, VAMC, room 5C114
Emergency Medicine Didactic Conference 1, Thursdays, 7:00 a.m. UAMS Education Bldg., room G/llOA&B
Emergency Medicine Didactic Conference 2, Thursdays, 8:00 a.m., UAMS Education Bldg., room G/llOA&B
Emergeiicy Medicine Didactic Conference 3, Thursdays, 9:00 a.m., UAMS Education Bldg., room G/llOA&B
Emergency Medicine Grand Rounds 1, Tuesdays, 7:00 a.m., UAMS Education Bldg., room G/llOA&B
Emergency Medicine Grand Rounds 2, Tuesdays, 8:00 a.m., UAMS Education Bldg., room G/llOA&B
Endocrinology Case Conference, Fridays, 7:30 a.m., ACRC 3rd floor conference room
Family Practice Grand Rounds, Tuesdays, 12:15 p.m.. Family Practice Center, 6th and Elm
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m.. Gastroenterology conference room, 3D29
Gl/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Radiology conference room, Ml/293
Hematology /Oncology Fellow's Forum, Fridays, 8:15 a.m., ACRC Betsy Blass conference room
Joint Cardiology-Cardiovascular Thoracic Surgery, Wednesdays, noon, UAMS, room S306
LR Cancer Conference, Wednesdays, 12:00 noon, UAMS ACRC conference room 3 times a month, CARTI Auditorium once a month
LR Vascular Conference, time & date varies monthly, rotates between UAMS, SVI & BMC
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education Bldg., room G/131A&B
Med/Path Conference, 3rd or 4th Tuesday, 3:00 p.m., UAMS Shorey Bldg., room S/306
Medicine Journal Club, alternate Thursdays, 7:30 a.m., ACC Medicine Clinic conference room
Medicine Research Conference, Wednesdays (except 3rd), 4:30 p.m. UAMS Education Bldg, room B/135
Neurology-Neuropathology Conference, Wednesday's, 4:00 p.m.. Room 2E-142 at VAMC
Neurology-Neuradiology Conference, Wednesday's, 5:00 p.m.. Room 2E-142 at VAMC
Neuroscience Clinical Grand Rounds, Monday's, 3:00 p.m., Betsy Blass Conference Room, Arkansas Cancer Research Center
Neuroscience Gonference (Basic), Mondays, 8:00 a.m., UAMS 7D33
Neuroscience Gonference (Basic & Clinical), Wednesdays, 4:00 p.m., UAMS 7C
Neurosurgery Journal Club, 2nd & 4th Thursdays, 8:00 p.m., 2 credit hours
Neurosurgical Pathology Conference, Thursdays, 4:00 p.m., VAMC-LR Neuropathology conference room, 2E141
OB/GYN Fetal Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education Bldg., room G/131B
Ophthalmology Problem Gase Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Ophthalmology Residency Morning Lectures, Mondays, Wednesdays, Fridays, 7:30 a.m., UAMS Jones Eye Institute
Orthopaedic Basic Science Conference, Tuesdays, 8:00 a.m., UAMS Education Bldg., room B/135
Orthopaedic Bibliography Conference, Tuesdays, 8:30 a.m., UAMS Education Bldg., room B/135, 1.5 credit hours
Orthopaedic Fracture Conference, Tuesdays, 7:30 a.m., UAMS Education Bldg., room B/135
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education Bldg., room B/135
Pathology Autopsy Conference, Wednesdays, 12:00 noon, VAMC-LR Morgue
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Basic Sciences Gonference, 1st Saturday, 7:30 a.m., ACRC 2nd floor conference room
Surgery Grand Rounds, Saturdays, 8:30 a.m., ACRC 2nd floor conference room
Surgery Morbidity & Mortality Conference, Saturdays, 9:30 a.m., ACRC 2nd floor conference room
Surgery Resident Case Conference, Saturdays (except 1st), 7:30 a.m., ACRC 2nd floor conference room
Trauma Morbidity & Mortality Conference, date & time varies monthly, ACRC 2nd floor conference room
Urology Adult Subject Oriented Conference, once monthly, 5:00 p.m., VAMC-LR, 4D
Urology Basic Sciences Conference, 2nd Tuesdays, 5:00 p.m., VAMC-LR, 4D resident office
Urology Clinical Didactic Conference, 3rd Tuesday, 5:00 p.m., VAMC-LR, 4D
Urology Formal Teaching (Grand) Rounds, once or twice monthly, 5:00 p.m., VAMC-LR, 4D
Urology Journal Glub, once a month, 5:00 p.m., VAMC-LR, 4D
Urology Morbidity & Mortality Gonference, once monthly, 5:00 p.m., VAMC-LR, 4D
Urology Pathology Gonference, 4th Thursday, 5:00 p.m., VAMC-LR, 4D
Urology Pediatric Gonference, once monthly, 5:00 p.m., ACH Sturgis Bldg., Clinic 2
Urology Pre-op/Didactic Conference, Mondays, 5:00 p.m., VAMC-LR, 4D
Urology Radiology Conference, 1st Thursday, 5:00 p.m., UAMS, Radiology Department
Urology Teaching Conference, Wednesdays, 5:00 p.m., VAMC-LR, 4D
Urology VA Teaching Rounds, every Friday, 7:30 a.m., VAMC-LR, 4D
Uro-radiology Conference (Urologic Imaging), 1st Tuesdays, 5:00 p.m., UAMS Radiology conference room
VA Chest Conference (combined Surgical/ Medical Chest Conference), Mondays, 12:15 p.m., VAMC-LR, room 2D109
VA Diagnostic Imaging Conference, Monday-Thursday, 8:00 a.m., VAMC-LR Nuclear Medicine conference room, room 1D173
VA GREEQ Geriatric Research Conference, Tuesdays, 4:00 p.m., VAMC-LR, room 2D109
60
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
VA Hematology/Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial ITospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, .2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
AHEC Residency Program Noon Conferences, 12:30 p.m., Tuesday-Friday, AHEC Building
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/ Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Holiday Inn
Independence County Medical Society, 2nd Tuesday, 7:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroradiology Conference, 3rd Friday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Volume 93, Number 1 - June 1996
61
Geriatrics Conference, 3rd Friday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Conference, 2nd & 4th Wednesday, 12:00 noon, Jefferson Regional Medical Center
Obstetricsl Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Thursday, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m., Pine Bluff County Club. Dinner meeting.
Surgery Conference, 1st Friday, 12:00 noon, Jefferson Regional Medical Center
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Wednesday, 12:30 p.m., St. Michael Hospital
Neuro-Radiology Conference, 2nd & 4th Tuesday, 12:00 noon, Wadley Regional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
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62
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Arkansas Medical Society
Presents Workshops
CPT & ICD-9
For Physicians & Medical Office Staff
CPT for Family Practice & Internal Medicine
Little Rock - July 16
Jonesboro - September 10
Springdale - October 1
El Dorado - October 1 5
ICD - for All Specialties
Little Rock - July 17
Jonesboro- September 1 1
Springdale - October 2
El Dorado - October 1 6
CPT - General Surgery
Little Rock - July 1 8
Jonesboro - September 12
Springdale - October 3
El Dorado - October 17
Watch for registration material to be mailed or
contact the AMS office at (501)224-8967 or
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Volume 93, Number 1 - June 1996
63
Advertisers Index
Advertising Agencies in italics
AMS Benefits 58
Arkansas Blue Cross & Blue Shield 63
Arkansas Children's Hospital back cover
Arkansas Managed Care Organization 4
Autoflex Leasing inside front
Care Network 25
The Alan Rothman Company, Inc.
Consumer Quote USA 7
Freemyer Collection System 36
Medical Protective Company 10
Williams Marketing Services
Riverside Motors, Inc 12
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory 46
Strategic Marketing
State Volunteer Mutual Insurance Company 2
The Maryland Group
UAMS-AHEC Program &
Tulane Medical Center inside back
U.S. Air Force 57
BJK&E Specialized Advertising
U.S. Air Force Reserve 1
HMS Partners, Inc.
U.S. Army Active 32
Young & Rubicam, Inc.
U.S. Army Reserve 62
Young & Rubicam, Inc.
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
journal. Material appearing in The ]ournal of the Arkansas
Medical Society is protected by copyright. Manuscripts
may not be reproduced without the written permission of
both author and The Journal of the Arkansas Medical Society.
The Journal of the Arkansas Medical Society reserves the
right to edit any material submitted. The publishers accept
no responsibility for opinions expressed by the contribu-
tors.
All manuscripts should be submitted to Tina G. Wade,
Managing Editor, Arkansas Medical Society, P.O. Box
5776, Little Rock, Arkansas 72215. A transmittal letter
should accompany the article and should identify one
author as the correspondent and include his/her address
and telephone number.
MANUSCRIPT STYLE
Author information should include titles, degrees,
and any hospital or university appointments of the
author(s). All scientific manuscripts must include an
abstract of not more than 100 words. The abstract is a
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stances.
Along with the typed manuscript, we encourage you
to submit an IBM-compatible 5 1/4" or 3 1/2" diskette
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References should be limited to ten; if more than ten
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ences should be numbered consecutively in the order in
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reference accuracy.
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are necessary, it is understood that the author(s) will be
responsible for the reproduction costs.
REPRINTS
Reprints may be obtained from The Journal office and
should be ordered prior to publication. Reprints will be
mailed approximately three weeks from publication date.
For a reprint price list, contact Tina G. Wade, Managing
Editor, at The Journal office. Orders cannot be accepted for
less than 100 copies.
THE Journal, s
OF THE Arkansas
MEDICAL SOCIETY
Volume 93 Number 2 July 1996
HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND, AT
BALTIMORE
Despite popular belief, the heavy, sticky
pollens of brightly colored flowers
seldom cause allergy symptoms, . ,
See article on page 8! to find out what
does cause allergic reactions and how
you can treat your allergic patients.
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE PRESIDENT
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
ObstetricstGyvecology
Internal Medicine
Surgery
Family Practice
UAMS
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
Volume 93 Number 2 July 1996
CONTENTS
FEATURES
68 The News and Weather Report: Bad Moon Rising
and 111 Winds Blowing
Editorial
Lee Abel, M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
71 Medicine in the News
Health Care Access Foundation Update
Thunderstorm- Associated Asthma: An Unusual Epidemic
Reading Mammograms Twice Makes a Difference
Physicians' Perceptions of Their Role in Health Promotion
Disciplinary Action Bulletin - Arkansas State Board of Nursing
77 New Member Profile
Erik ]on Wait, M.D.
79 Basic Rules of Being an Expert Witness
Legally Speaking
David L. Ivers, J.D.
81 Nothing to Sneeze About; Allergies •
and Allergic Rhinitis
Special Article
]im Mark Ingram, M.D.
I Cover Story
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information: Contact Tina G. Wade, The
Journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
Press, Inc., Fulton, Missouri 65251. Periodicals postage
is paid at Little Rock, Arkansas, and at additional
mailing offices.
Articles and advertisements published in The Journal
are for the interest of its readers and do not represent
the official position or endorsement of The Journal or the
Arkansas Medical Society. The Journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1996 by the Arkansas Medical Society.
DEPARTMENTS
75 AMS Newsmakers
89 Cardiology Commentary & Update
93 State Health Watch
96 Arkansas HIV/AIDS Report
99 New Members
101 Radiological Case of the Month
105 In Memoriam
105 Things to Come
107 Keeping Up
Cover photograph taken by A.C. Haralson of the Arkansas Department of Parks & Tourism.
Editorial
The News and Weather Report:
Bad Moon Rising and III Winds Blowing
Lee Abel, M.DA
I once read a curious fact about the human heart.
The human heart (referring to the metaphysical or-
gan, not the pump) can hold fear or love but not both
at the same time. When we are feeling love and its
attendant emotions of happiness, forgiveness and trust,
we are unable to experience fear and its attendant
emotions of anger, suspicion and mistrust.
These thoughts were occasioned by a patient of
mine - a middle aged woman with high blood pres-
sure, anxiety and panic attacks. Though I believed my
diagnoses were correct and my choice of medications
reasonable, she did not have the improvement I had
hoped for. There developed a pattern to her office vis-
its. She would begin by telling me her various symp-
toms, but then would also tell me how upset she was
about something she had seen on the local TV news.
Often I had only minimal or no knowledge of the child
kidnapping or other tragedy that she was so distraught
over. I finally asked her why she faithfully watched
the news every night, given how much it upset her.
She replied that she felt she should watch it because it
was "reality," and that to not do so would be a sign of
weakness.
The local TV news does show us one aspect of
reality. We are shown traffic jams, car wrecks and over-
turned trucks; fires, floods and explosions; shootings,
drug busts, murders and other examples of the hei-
nous behavior we humans are capable of inflicting on
ourselves and on others. It only takes watching for
about a week to know the routine. The chosen may-
hem is predictable and the presentation is flashy but
quite formulaic. In fact, a week of the local news in
any city is sufficient, because it is remarkably homo-
geneous across the nation. The triple murder will re-
ceive more coverage than the single homicide unless
the single homicide has some hint of juicy scandal,
and then it will take precedence over mere numbers.
Some stations may adopt a raw in-your-face tabloid
style, while others claim a kinder gentler style. For all
the stations' assertions of seeing (or as Channel 11
claims, "feeling") a difference, they are all dancing to
* Dr. Abel specializes in internal medicine and is affiliated with
the Little Rock Diagnostic Clinic. He is a member of the edito-
rial board for The Journal of the Arkansas Medical Society.
68
the same tune.
The TV news approach to reality is well seen even
in their coverage of the weather. The weather features
prominently on the local news perhaps because it is
such an easy way to fill up time. Some of their cover-
age is merely banal. A storm topples a tree onto
someone's house. The attractive TV personality shoves
a microphone into the hapless homeowner's face and
earnestly asks, "How does it feel to have a large tree
on top of all your worldly possessions?"
Some of their weather coverage takes on a dark
and ominous tone marked by a good dose of hype
(but the weatherperson is always very friendly and
nice). The emphasis is on storms or difficult weather
that may come about, the severity and danger of the
present conditions and on what can best be called the
weather related body count. Though nature is power-
ful and must be respected, some people seem to have
lost sight of how adaptable humans are. I have pa-
tients who seem to have been persuaded that Arkan-
sas is a truly hostile environment. We are told the
numbers - the wind chill, the pollution index, the pol-
len count, the UV index and the heat index. If this
information causes a "batten down the hatches" men-
tality, we increase our isolation from others and from
the beauty of the natural world. A more peaceful and
informative way to know the weather is to get up from
the La-z-boy (glance at the weather map in the news-
paper if you must) and take a walk.
We do need to stay connected to what is happen-
ing in our local communities. Apathy and ignorance
are roadblocks to a better community. A friend recently
reminded me that we usually get the government we
deserve. The TV news with its focus on the superficial
does not contribute to the deeper understanding we
need. It gives us too much mindless chatter and infor-
mation clutter. Their take on reality is too colored by
fearmongering and sensationalism which is intended
to keep viewership (and advertising rates) up. The
newspapers are not free of these traits, but one is given
more substance in a more efficient manner, and the
format leaves the consumer with more control.
Local TV news programs have made attempts to
be more positive, but this often takes the form of gos-
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
sipy celebrity fluff or maudlin human interest stories.
They profess to give us "news you can use" but their
attempts seem largely hollow and off key. For example,
Channel 11 recently ran an ad touting "11 Reasons to
Watch News Channel 11." These reasons included (ex-
act quotes): 1) Your child is missing! What do you do? We
have the information you need to know; 2) You trust your
doctor, but do you really know him? Find out how to check
out your physician; 3) Doppler 11 Radar. Tracking storms
as quickly as they form; 4) How do you become Miss Uni-
verse? Find out what it takes to win the crown; and my
favorite (for its complete unawareness of the irony): 5)
Is junk mail taking over your mailbox? Larry Audas shows
you how to get off all those mailing lists. (As if, the adver-
tisers who sponsor the TV news are somehow differ-
ent from the ones who send us mail. The biggest source
of junk advertising in the typical U.S. household is
the kind that arrives blaring from the tube, not the
kind that silently fills up the mailbox.)
My intention is not to demonize the local TV news.
The truth is, we are attracted to the lurid. This being
so, the media will continue to give us the grisly de-
tails. It is also true however, that we have a side that is
attracted to the inspiring and uplifting. All of us get to
choose how much time we spend on the lurid and
inane versus how much time we spend on the more
meaningful. Is the TV version of reality the one our
children need to see each evening? If the local news
makes us feel more fearful, more distrustful of our
neighbors, if it makes us feel more negative, cynical
and passive, then can it be healthy for our metaphysi-
cal heart or our beating heart?
The late Methodist minister. Dr. James B. Argue,
said that although we may pray for blessings, we of-
ten don't recognize them when they occur. Things
that we fervently pray for may prove disastrous, while
things that seem a setback, may later reveal themselves
to have been quite the opposite. Our individual vision
is limited. We are indeed the proverbial blind men
feeling only a part of the elephant, and so humility is
in order.
There is a deep mystery to life; good can some-
times come from bad. The bad moon and the ill winds
can give rise to the generous sun and the cool breeze.
Still, for my patients facing challenging medical prob-
lems, I will advise that they take care with the images
they plant in their minds. Healing sometimes requires
more than the correct pill or timely surgery, so I will
try to remember that love and laughter can be power-
ful medicine. The TV news won't make the prescrip-
tion list.
MONTANA TROUT FISHING
BLACK FEET INDIAN RESERVATION
with James R. Weber, M.D.
August 20 - 26, 1996
This August trip provides superior fishing for huge brown trout. The picture is of Alan Storeygard,
M.D., of Jacksonville from our May 1996 Montana trip with 12 doctors. Everyone caught many 10 to
12 pound rainbow trout. In August, you will experience unbelievable brown trout fishing with superior
guides in one of America’s most beautiful settings. The trip is limited to 12 people, so book today.
*Down Payment - $250.00 Per Person
*Total cost Excluding Airfare Approximately
$1,000.00 Per Person
*3 Fishermen Per Guide
*Fly Fishing, Primarily With Float Tubes
*Perfect for the Novice as well as the
Experienced Fisherman
Any equipment you might need can be purchased at
discount through Specialty Outfitters.
To book your reservations
call Specialty Outfitters (501)985-0744.
a
Volume 93, Number 2 - July 1996
69
The More
You Know
About Us,
The More
YouTl
Prefer U s .
ouTl prefer us, because you are us. Arkansas Managed Care
Organization is the physician sponsored PPO designed to fit the
needs of your local community. More than 1 ,500 physicians state-
wide have found AMCO is the managed care solution that works on
their turf.
To find out more about AMCO, give us a call. You’ll like what you
hear.
Y
Arkansas
Managed Care
Organization
#10 Corporate Hill Drive
P.O. Box 23803, Little Rock, AR 72221-3803
(501) 225-8470 • Fax (501) 225-7954
Medicine in the News
Health Care Access Foundation
As of June 1, 1996, the Arkansas Health Care Ac-
cess Foundation has provided free medical service to
11,092 medically indigent persons, received 20,246 ap-
plications and enrolled 39,895 persons. This program
has 1,711 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
Thunderstorm-Associated Asthma:
An Unusual Epidemic
The increased incidence of asthma in recent years
has raised the possibility that certain environmental
conditions may precipitate attacks. Periodic reports of
outbreaks after thunderstorms have heightened this
suspicion. Two reports on a large London outbreak
that happened after a major thunderstorm in June 1994
allow a more extensive look at the phenomenon.
The first study characterized the patients involved
in the outbreak. During the 30 hours after the storm,
640 people visited London emergency rooms for asthma
or other airway disease - 10 times the expected level.
Among these, 403 had a history of hay fever and 283
had no prior history of asthma attacks. Grass pollen
counts were exceptionally high during the two days
before the outbreak.
The second study characterized the environmen-
tal conditions around the time of the outbreak. Two
major changes occurred right before the outbreak: a
drop in air temperature and a rise in grass pollen
counts. During other times in the two months before
and after the outbreak, nonepidemic asthma was sig-
nificantly associated with the number of lightning
strikes, increased humidity of sulfur dioxide concen-
trations, a temperature drop or high rainfall the previ-
ous day and a decrease in maximum air pressure or
changes m grass pollen concentrations over the previ-
ous two days.
Comment: An accompanying editorial supports the
conclusions of these two papers: epidemic asthma af-
ter a thunderstorm is a unique entity, probably re-
lated to marked increases in grass pollen concentra-
tions, which may affect a population that doesn't usu-
ally suffer from asthma. - KI Marton
Thames Regions Accident and Emergency Trainees As-
sociations. A major outbreak of asthma associated with a
thunderstorm: experience of accident and emergency depart-
ments and patients' characteristics. BMJ 1996 Mar 9;
312:601-4.
Celenza A; et al. Thunderstorm associated asthma: a detailed
analysis of etivironmental factors. BMJ 1996 Mar 9; 312:604-7.
Bauman A. Asthma associated with thunderstorms: grass
pollen and the fall in temperature seem to he to blame. BMJ
1996 Mar 9; .312:590-1.
Reprinted by permission of Journal Watch, Volume
16, Number 9, May 1, 1996 issue. Copyright 1996. Massa-
chusetts Medical Society.
Reading Mammograms Twice
Makes a Difference
The optimal strategy for interpreting mammograms
is uncertain. This British study of 33,734 women com-
pared three methods: a single reading by one radiolo-
gist; consensus double reading (by two radiologists
who either agreed about whether to recall the patient
for further examination or followed the recommenda-
tion of a senior radiologist); or non-consensus double
reading (by two radiologists, either of whom could
recall the patient if they disagreed). In actuality, the
consensus double reading method was applied to all
the women, but the researchers inferred recall rates
for the other two strategies based on the radiologists'
individual recommendations.
The single-reading method would have detected
71 cancers per 10,000 women, compared with 80 for
non-consensus double reading. The proportion of
women recalled for further assessment was higher with
non-consensus double reading (9.9%) than with single
reading (6.9%) or consensus double reading (4.2%).
Compared with single reading, consensus double read-
ing saved roughly $7,300 per 10,000 women screened,
while non-consensus double reading cost about $29,000
more per 10,000 women.
Comment; Consensus double reading of
mammograms clearly dominated in this study, detect-
ing at least as many cancers as the other two strategies
but costing the least. - KI Marton
Brown ]; et al. Mammography screening: an incremen-
tal cost effectiveness analysis of double versus single reading
of mammograms. BMJ 1996 Mar 30; 312:809-12.
Reprinted by permission of Journal Watch, Volume
16, Number 10, May 15, 1996 issue. Copyright 1996. Mas-
sachusetts Medical Society.
Physicians' Perceptions of Their Role in
Health Promotion
In 1981, researchers surveyed primary care physi-
cians in Massachusetts about their perceived role in
health promotion. The same team now presents the
findings of a similar survey done in 1994. Most physi-
cians believed that eliminating smoking, avoiding il-
licit drugs, using seat belts and limiting alcohol and
saturated-fat intake were "very important" for patients;
Volume 93, Number 2 - July 1996
71
more physicians in 1994 than in 1981 rated each be-
havior as very important. However, fewer physicians
in 1994 believed that avoiding excess calories and eat-
ing a balanced diet were very important.
From 1981 to 1994, an increasing number of physi-
cians saw educating patients about risk factors and
helping patients follow health regimens as part of their
role. But ironically, fewer physicians in 1994 consid-
ered it their responsibility to provide patients with
emotional support, to encourage them to discuss per-
sonal problems, to educate them about community
resources and to involve family members in their care.
Comment: Educating and counseling patients
about health promotion requires considerable time,
effort and skill. One can only wonder whether the
physicians' perception of less responsibility for certain
types of personal counseling in 1994 is a response to
time pressures and limited reimbursement under new
health care arrangements. - AS Brett
Wechsler H; et al. The physician's role in health promo-
tion revisited - a survey of primary care practitioners. N
Engl J Med 1996 Apr 11; 334:996-8.
Reprinted by permission of Journal Watch, Volume
16, Number 10, May 15, 1996 issue. Copyright 1996. Mas-
sachusetts Medical Society.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board office should be contacted. There-
fore, we routinely suggest this list be shared with the
appropriate supervisory personnel and recruiters in
your office.
At the completion of the disciplinary period, the
nurse applies for reinstatement. Reinstatement is con-
tingent upon meeting the conditions set forth by the
Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY: May 8. 1996
^Bradley Phillips Middleton, LPN 27603 (Mabelvale)
Permission to renew license granted with 2-year probation
^Cynthia Lou Pate Cross, RN 31050 (Ft. Smith) Probation -
3 years
*Kevin George Howell, LPN 31822 (Jacksonville, NC)
Suspended unhl North Carolina license has been cleared
’''Leslie Anne Haralson, Impostor (Ft. Smith/
Fayetteville) Fined $5,000
’''Susan Rita Glasscock, RN 33549 (Baptist Health, Little
Rock) Suspension - 2 years
’''Terrie Carol Martin Heard, LPN 29150 (Homer, LA)
Suspension - 3 years
VOLUNTARY SURRENDER:
’'^Mary Ellen Hankins, RN 12394 (DeQueen) April 16
’''Earl LeRoy Goodhart, Jr., LPN 29490 (Farmington)
April 17
OFF PROBATION:
“'Amanda N. Gilliam, RN 43730 (Texarkana, TX) April 29
’'Rose M. Langley, LPN 19840 (Mayflower) April 25
’'Robert Hal Bodenhamer, RN 16272 (Mt. Home) May 3
LETTER OE REPRIMAND:
“'Debra June Williams Honey, RN 33793 (Newport)
April 22
“'Cynthia Ann Wilkerson Dunseath, LPN 13170
(Conway) April 23
“'Jane Kay Jones Keck, LPN 26787 (Batesville) April 23
“'Debby Kay McCune Worden, LPN 31542 (DeQueen)
April 24
“'Norman Willis Whitten, LPN 29372 (Bearden) April 24
“'Carla Jeannine Blanchard Unger, LPN 16823 (Flippin)
April 24
“'Cindy Paige Gardner Limbaugh, LPN 27878 (Sulphur
Rock) April 24
“'Mary R. Swearingen Everett, LPN 14824 (Springdale)
April 23
“'Cindy Gayle Champion Barton, LPN 32596 (Conway)
April 23
“'Lillian Ann Stone Coke, LPN 6580 (Hot Springs) April 23
“'Melna Jean Aaron Berryman, LPTN 1251 (Benton)
April 24
“'Tiffany Lynn Oliver, LPN 30207 (Nashville) April 24
“'JoAnn Rhodes, RN 25246 (Muldrow, OK) April 24
REINSTATEMENT:
“'Suellen West Wooten, RN 28075 (Jonesboro) April 24
“'Frances Kay Christopher, RN 24838 (Sallisaw, OK)
April 25
ALERT:
If you have employed the following nurse or have
any knowledge of her whereabouts, please notify the
Board of Nursing at (501)686-2700:
“'Carolyn Joyce Vann Hayden, LPN 25559
72 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
I
Testing I
A Look at the Laboratory
at Arkansas Children’s Hospital
What goes on in the laboratory at
Arkansas Children’s Hospital? More than
500,000 laboratory tests a year, that’s what.
From a few drops of blood or a tiny amount of
tissue, our pathologists, technologists and
technicians can discern a world of information.
It’s more than test tubes and microscopes.
Our specialized personnel and equipment
make us a leader in lab technology — we per-
form some tests that no one else in the state is
equipped to do. We work precisely enough to
examine DNA and fast enough to help physi-
cians make important treatment decisions —
every hour of every day of the year.
Here are some of the people who helped
us pass our “lab test” well enough to be
accredited by the College of American
Pathologists: (back row, from left) Cynthia
Holland, Administrative Director of
Laboratories; Valleria Gaines, Certified Lab
Assistant, Nights; Keith Gilstrap, Medical
Technologist, Virology; Ronald Artis, Lab
Assistant, Blood Bank; Ruth Ready, Medical
Technologist, Evenings; (front row, from left)
Linda Andries, Assistant Administrative Lab
Director; Stacey McVey, Medical
Technologist, Hematology; Andrea Pfeifer,
CLSp, Cytogenetics; Peggy Casey, Medical
Technologist, Immunology/Histology;
LaTonia Shelton, Medical Lab Technician,
Chemistry; Cindy Weaver, Medical
Technologist, Microbiology and Delores Ware,
Lab Assistant, Receiving.
ARKANSAS
CHn.DRFMS
HOSPITAL
OI/LDReH'5 //VfeS
800 Marshall Street
Little Rock
(501) 320-1 100
Moke sure Arkonsos Children's
Hospital is included in your
employee health plan. For more
information, call our Managed
Core Hotline at (501) 320-6656.
SPECIALIZE
IN AIR FORCE
MEDICINE.
ER Physicians. Radiolo-
gists. OB/GYNs and
other specialists!
Today’s Air Force gives
you the freedom to spe-
cialize without the finan-
cial overhead of running
a private practice. Talk
to an Air Force medical
program manager about
the tremendous benefits
of becoming an Air
Force medical officer:
• No office overhead
• Dedicated, profession-
al staff
• Quality lifestyle and
benefits
• 30 days vacation with
pay each year
Examine your future in
the Air Force. Learn if
you qualify. Call
USAF HEALTH PROFESSIONS
TOLL FREE 1-800-423-USAF
AMS Newsmakers
Dr. Les Anderson, a family practitioner, was re-
cently honored as the 1996 Citizen of the Year during
the Lonoke Chamber of Commerce banquet.
Charles Tucker, M.D.
The office of Dr.
Ronald Ganelli, a sur-
geon, recently joined
the Wynne Chamber of
Commerce. Mark Tay-
lor (on the left) of the
Chamber presented
Dr. Ganelli with a
membership plaque.
Dr. John Lytle, a
Pine Bluff orthopedic
surgeon, recently Ronald Ganelli, M.D.
spoke during a session
of "The Doctor Is In" at The Arts & Science Center.
His discussion on sports medicine was titled "Don't
Take Me Out of the Ball
Game."
Dr. Charles Tucker, a
family practitioner of Ash
Flat, was recently recog-
nized by the Sharp County
and quorum court mem-
bers for his many years of
commitment to the county.
He has been practicing
medicine for more than 28
years.
Drs. James D. Mashburn and Arthur F. Moore
were recently named recipients of the 1996 Eagle Award
given by Washington Regional Medical Foundation for
their outstanding health leadership in Northwest Ar-
kansas.
ceived $1,000, a crystal flame award and automatic
entrance into the national JCPenney 1996 Golden Rule
Award competition. These awards are presented each
year to seven volunteers or groups of volunteers who
exemplify outstanding community service.
(From left) Pat Keller, Project Director of the Arkansas
Health Care Access Foundation, with Betty Bumpers at the
JCPenney Golden Awards Banquet in Russellville.
Pat Keller, Project Director of the Arkansas Health Care
Access Foundation, accepting the award at the JCPenney
Golden Awards Banquet in Russellville.
Arkansas Health Care Access Foundation
(AHCAF), Inc. was recently honored as the group
winner of the JCPenney Golden Rule Award for the
Central Arkansas area. In addition, AHCAF was named
a semi-finalist in the River Valley area of Russellville
and received $250. As the group winner, AHCAF re-
Christopher Adams, Little Rock; Lester T.
Alexander, Pine Bluff; Ron William Beckel, Little Rock;
Elizabeth Ross Chambers, Harrison; Jay Douglas Hol-
land, Little Rock; Matthew Kyle McAlister, Mountain
Home; Robert Lyle Morris, Harrison; Debra Jo
Morrison, Little Rock; Mose Smith, Little Rock; Aubrey
Lawrence Travis, Van Buren.
Volume 93, Number 2 - July 1996
75
Each year, more than 6,000 children like Adam learn all about cancer and
other catastrophic illnesses when they're stricken with deadly diseases.
Fortunately, these children have a fighting chance at surviving cancer —
the No. 1 killer disease of children — because of strides St. Jude doctors
and scientists are making every day in treatment and research. With your
support, St. Jude Children's Research Hospital is helping children all over
the world live.
To find out /nore about 5f. Jude *5 life-saving work, write to:
5t. Jude Hospital • P.O. Box 370U, Dept. DA • Me^nphi5,TM 38103, or call:
1-800-877-5833
— ST. JUDE CHILDREN’S
RESEARCH HOSPITAL
Danny Thomas, Founder
r Profile
Erik Jon Wait, M.D,
PROFESSIONAL INFORMATION
Specialty: Obstetrics & Gynecology
Years in Practice: One
Office: Malvern
Medical School: University of South Dakota, Vermillion, 1991.
Internship: University of Missouri, Columbia, 1992
Residency: University of Missouri, Columbia, 1995
Business and other affiliates: First United Methodist Church, AMA and Rotary
Honors! Awards: AOA, Teaching Excellence Award in Residency and a Medical Publication Award.
PERSONAL INFORMATION
Children: Brittni, 8; Devin, 5; and Ava, 3
Date/Place of Birth: June 2, 1963 - Sioux Falls, S.D.
Hobbies: weight lifting, mountain bike riding, archery and motorcycles
THOUGHTS
Favorite junk food: pizza
People who knew me in medical school, thought I was: good-natured, even-tempered and funny.
Favorite vacation spot: Caribbean (St. Thomas)
One goal I am proud to have reached: finishing residency
Favorite childhood memory: sailing with my father
When I was a child, I wanted to grow up to be: a physician
First job: sacking race horse oats at age 14
Worst job: sacking race horse oats at age 14
My life philosophy: Enjoy!
If you are interested in appearing in either the New Member Profile
or Member Profile, contact Tina Wade at the Arkansas Medical So-
ciety at (501) 224-8967 or 1-800-542-1058.
Volume 93, Number 2 - July 1996
77
The Doctors Advisory Network
You make the call. We make the connection.
Free referrals. A free phone call. What
could possibly be better? How about
a choice of top-line, managed care
experts in your neck of the woods?
One call to the Doctors Advisory
Network is all it takes to access
physician-friendly lawyers, business
consultants and actuaries. As a
member of the American Medical
Association (AMA), you can use this
service any time you need it — free!
Nonmembers pay a nominal fee.
The Doctors Advisory Network has
made more than 4,000 referrals across
the country.
You’ll receive a Network starter kit
including a complimentary booklet —
A Physician's Guide to Selecting
and Working with a Managed Care
Attorney or Consultant.
Call toll free 800 AMA-1066, and press 2.
The Doctors Advisory Network.
Your direct line to managed care
solutions.
American Medical Association
Physicians dedicated to the health of America
Legally Speaking
Basic Rules of Being
an Expert Witness
David L. Ivers, J.D.*
Most doctors would rather do just about anything
than be a witness in court. It's tedious, time consum-
ing and you have to put up with all those obnoxious
attorneys. But love it or hate it, most physicians prob-
ably will end up in the hot seat sometime during their
career, often repeatedly. Following are some basic rules
of thumb for those auspicious occasions.
Types of Witnesses
You could be involved in a lawsuit as an ordinary
lay witness, such as someone who has observed an
automobile accident. However, as a physician, if you
are called as a witness, odds are it will be as an expert.
Basically, there are two kinds of expert witnesses.
One is a "hands-on" or fact expert. In this role, you
have actually been a part of events that transpired in
the case. An obvious example is a physician who
treated the plaintiff in a car wreck case. The second
type of expert is the paid consultant, a nonfact expert
who is highly qualified in his or her field and has been
hired specifically to testify in this case.
Where You Will Testify
You will either testify on the witness stand in the
courtroom or in a deposition in an attorney's office.
Don't be fooled. A deposition is just as important as
live testimony in the courtroom.
A deposition is designed to allow the opposing
counsel to determine what your testimony is going to
be in court, what evidence you are relying on, how
you drew your conclusions, and similar matters. Dur-
ing a deposition you are under oath and your testi-
mony is recorded, just as if you were in court. If you
later change your testimony in court, your deposition
win be used to point out the discrepancies, i.e. to "im-
peach" you.
* David L. Ivers, J.D., is an associate with Mitchell, Blackstock
and Barnes in Little Rock, general counsel for the AMS.
Also, it is common practice these days for experts
to give two depositions, the discovery deposition and
then an "evidentiary deposition." The evidentiary
deposition is often on videotape. The video is then
played at the trial, and the physician does not actually
have to come to court.
Your Qualifications
Typically, the attorney who calls you will first have
you introduce yourself and briefly explain why you
are testifying. The attorney then will likely question
you about your qualifications. The attorney calling
you has to establish that you have the requisite "knowl-
edge, skill, experience, training, or education" under
Rule 702 of the Arkansas or Federal Rules of Evidence
to qualify as an expert.
The attorney will probably insist that you give your
qualifications, even if the other side says it is not nec-
essary. But don't go overboard. A good attorney will
take you down a path that is impressive, but sticks to
qualifications pertinent to the issue at hand, and does
not become flagrant boasting that irritates the jury.
Also, the attorney may choose to weave in your quali-
fications at relevant points during your testimony in-
stead of using a shotgun approach at the beginning.
The Type of Testimony You Will Give
The type of testimony you will give obviously de-
pends upon whether you are a fact witness or a hired
expert. Generally, though, under Rule 702, anything
that "will assist the trier of fact to understand the evi-
dence or to determine a fact in issue" is fair game.
That leaves wide latitude for questioning under either
category of witness.
After your qualifications, you will usually state
your conclusions and then go into some detail about
the underlying bases for those conclusions. In the
past there were concerns with the frequent situation
Volume 93, Number 2 - July 1996
79
in which experts based their opinions on what they
learned from other persons, which created a hearsay
problem. However, in recent years, the law has fi-
nally recognized this process as the legitimate and re-
alistic way in which experts function in everyday life.
Therefore, under Rule 703, if the evidence is of a type
"reasonably relied upon by experts in the particular
field in forming opinions or inferences on the subject,
the facts or data need not be admissible in evidence."
As a simplified example, this means that you can
testify as to why you believe that the patient was over-
dosed at the hospital, even if part of your basis for this
opinion is the nurse's charts instead of first-hand ob-
servation of the excess drug being administered. You
can also rely on articles and treatises in your field,
studies conducted by other experts and similar sources.
The "Ultimate Issue" and "Magic Words"
A long-running debate in legal circles has focused
on whether experts should be able to testify as to the
"ultimate issue" in a case. Through Rule 704, it is
now permissible for experts to give an opinion even if
it goes to the very question the jury is to decide, e.g.,
did the automobile accident cause the herniated disc?
The only exception is that the Rules do not allow ex-
perts to testify to the mental conditions of defendants
in criminal cases.
The Rules also have done away with the require-
ment for certain "magic words" in expert testimony,
but attorneys today still frequently use them. Typi-
cally, after background discussion the questioning goes
like this:
Q: On the basis of this information, do you have
an opinion to a reasonable degree of medical certainty as to
the cause of Mr. Pain's condition?
A: I have an opinion.
Q: What is that opinion?
And so on. Technically, there is no requirement
that your opinion have any more stringent proof re-
quirement than other evidence, usually a mere prob-
ability ("preponderance of the evidence"). Neverthe-
less, you will still be asked this type of question in
many cases, and for all practical purposes, it rarely
poses a problem for experts.
In conjunction with the magic words, many attor-
neys will ask you a long, detailed "hypothetical ques-
tion." This device was originally designed to avoid
problems with non-fact witnesses testifying based on
facts of which they had no personal knowledge. Thus,
a hypothetical question with all the same facts was created.
80
While use of the hypothetical question is no longer
necessary under the Rules, it is often a useful tool,
and the attorney who uses it should give the question
to you in advance so you will be prepared. Be pre-
pared also for the opposing counsel to vary the facts
in the hypothetical, and then ask you your opinion.
Learned Treatises
Many times the opposing counsel will ask you
about a particular treatise or author and ask you if you
recognize that article or that person to be authoritative
on the subject at issue. Obviously, the attorney has
found a differing view. Under the Rules, the oppos-
ing article is probably going to come into evidence one
way or the other. That does not mean you have to
agree that it is authoritative. But you should be pre-
pared to recognize its existence and state why you
disagree with its conclusions. You should also expect
that the opposing counsel has reviewed all of your
published works and will point out any perceived in-
consistencies between those works and your testimony.
How much will you get paid?
Under the Rules of Civil Procedure you are gener-
ally entitled to a "reasonable fee" for your time spent
in responding to discovery. The amount is usually
based upon an hourly rate which could be earned in
your practice. In Arkansas, the amount rarely exceeds
$200 per hour. When it comes to testifying in court,
you are only entitled to be reimbursed $30 per day
plus mileage, unless a different agreement is worked
out with the party calling you. Also, unless you are
hired as an expert, insist on a subpoena for both depo-
sition and trial. This helps avoid the appearance of
bias or over-eagerness.
What To Wear
The sage advice still holds on what to wear: dress
conservatively. Usually this means a dark blue suit,
well-groomed hair, nothing flashy to detract from your
testimony or credibility. No ponytails for men, no
gaudy jewelry for men or women.
In the next Legally Speaking: Specific things to do
and not to do for witnesses under direct and cross
examinations.
Sources:
1. James W. McElhaney, McElhaney's Trial Notebook (3d ed. 1994).
2. Mark L.D. Wawro, "Effective Presentation of Experts,"
19 Litigation 31, American Bar Association (Spring 1993).
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Special Article
Cover Story
Nothing to Sneeze About: Allergies and
Allergic Rhinitis
Jim Mark Ingram, M.D.’*'
Allergies are a very common problem around the
United States, including Arkansas. It is estimated that
up to 40 million Americans (20-25%) have some form
of allergic or atopic diseases. The terms atopic and
allergic are frequently interchanged. In its broadest
sense, the term allergy has been used in the past to
describe any immunologic alteration in the capacity to
react following contact with a foreign substance. Atopic,
on the other hand, characterizes conditions produced
by IgE-mediated hypersensitivity. Genetic factors play
an important role in the susceptibility to these dis-
eases. Patients inherit the tendency for allergies, not
the specific allergies that their parents may have. An
IgE response occurs normally in all individuals, but
the presence of immune-response genes are needed
for clinical manifestations to occur.
The Allergic Reaction
The essential components of allergic reactions in-
clude allergens, IgE antibodies directed at antigenic
determinants on the allergen and mast cells. In order
to initiate allergic responses, exposure to an appropri-
ate antigen and a genetically determined capacity to
respond with IgE production are required. Antigen
presentation requires access of antigens to the mu-
cous membrane, uptake by antigen-presenting cells,
antigen processing and stimulation of local antibody
production. IgE production occurs in the same local
environment as antigen presentation, probably in the
draining lymph nodes. The IgE that is produced sen-
sitizes mast cells in the same environment by binding
to high-affinity receptors for IgE on the cell surface.
Although no one is certain, the production of suffi-
cient IgE to render a subject allergic is thought to take years.
Once sensitized, mast ceils may degranulate on
subsequent allergen exposure. The bridging of IgE re-
ceptors by aggregation of IgE molecules bound to
multivalent allergens initiates a biochemical reaction
that leads to the secretion of a range of chemical mediators
* Jim Mark Ingram, M.D., is with the Little Rock Allergy and
Asthma Clinic.
from mast cells. These mediators then interact with
surrounding tissues and elicit the allergic responses,
the nature of which is determined by the local envi-
ronment. Thus, mast cell mediators may cause rhini-
tis, conjunctivitis, sinusitis, cough, asthma, abdomi-
nal cramping, diarrhea, urticaria, eczema, headaches,
hypotension, laryngeal edema and other consequences
depending on the local environment.
Allergens: The Reason behind the Sneezing
Inhalant allergens are most frequently involved in
allergic respiratory diseases, such as allergic rhinitis
and asthma. These antigens, which directly impact on
the respiratory mucosa, are usually derived from natu-
ral organic sources, such as house dust, pollens, mod
spores, and insect and animal emanations. It appears
that most particulate aeroallergens are 2 to 60 um in
diameter, and their allergenic constituents usually are
proteins.
Inhalant allergic diseases may be episodic, seasonal
(such as hay fever) or perennial. The most apparent
seasonal allergens are pollens. Most tree pollens are
released during the early spring. In most parts of the
country, the height of the grass pollen season is late
spring to midsummer. Although some species of weed
pollen are airborne in spring and early summer, the
greatest difficulty from weeds is in late summer and
early fall. Despite popular belief, the heavy, sticky
pollens of brightly colored flowers seldom cause al-
lergy symptoms, as these pollens are spread by in-
sects and not by wind currents. Inhalant allergens are
most often responsible for rhinitis, conjunctivitis or
asthma, although occasionally, urticaria or systemic
anaphylaxis may occur. The two common misnomers,
"hay fever" and "Rose fever," relate to the season of
ragweed and grass pollenosis and are not associated
with fever.
Exposure to non-seasonal allergens mainly through
inhalation but in some instances by ingestion, accounts
for year-round allergies. Among the inhalants, dust
mites, mold spores, cockroaches and animal emanations
Volume 93, Number 2 - July 1996
81
Table 1
The Allergy Seasons in Arkansas
Early Spring (February-May)
Tree pollens (elm, oak, hickory and pecan)
Late Spring (May-June)
Grasses (bermuda, bahia, june and timothy)
Summer (July-August)
Ground or outdoor molds (Alternaria and Cladosporium)
Fall (mid-August-October)
Ragweed (plus secondarily, cocklebur, lambs'-quarter,
pigweed and plantain)
Winter (November-February)
Dust mites, animal emanations, cockroaches, household
molds (Aspergillus, Penicillium, Alternaria and Cladosporium)
are responsible for most perennial allergic rhinitis and
asthma. Avoiding outdoor exposures to ubiquitous
pollens and mold spores is difficult, but common sense
measures to avoid unnecessarily heavy exposures may
help. For example, camping and hiking are preferably
done other than during the pollen season; mold-sen-
sitive patients generally should avoid barns, hay, rak-
ing leaves and mowing grass; driving in air-conditioned
vehicles is preferable; air-conditioning the house greatly
reduces pollen in the indoor air; and closing bedroom
windows during the pollen season is useful. High-
efficiency particulate air filters are somewhat useful in
reducing airborne allergens in small spaces, such as a
bedroom.
When cost is not a significant consideration, in-
stallation of both an air conditioner and a high-effi-
ciency particulate air filter or electronic filter in the
central duct work of homes with forced hot-air heat
may be considered.
House dust itself is a mixture of lint, mites, mite-
derived feces, danders, insect parts, fibers and other
particulate materials. Overwhelming evidence indicates
that certain mites, Dermatophagoides farinae and
Dermatophagoides pteronyssinus, are the principal
sources of antigen in house dust. These arachnids
encase their fecal materials in a coating rich in intesti-
nal enzymes, and it is a protease within this coating
that is the primary allergen. Mite fecal balls are large
and heavy compared with other allergens, and thus
only float in the air briefly after disturbance. Mites
living in bedding, mattresses and carpets feed on hu-
man skin dander and require a warm, relatively hu-
mid environment to proliferate (65 to 70F) tempera-
ture and >50% relative humidity. They survive best in
carpets, bedding and upholstery. Disturbance of the
carpet perhaps by vacuuming, leads to a brief (30 min-
utes or so) episode of airborne mite feces, leading to
inhalation and possible initiation of allergic reactions.
Control of mites is aimed at eliminating the sites where
mites survive best (remove carpets and "dust traps,"
encase bedding, and wash curtains and bedclothing
in hot (130F) water. The use of acaricides on carpets to
kill the mites might also be considered.
Cat allergens, derived from both salivary and skin
sources, are much smaller and lighter than dust aller-
gens. Found constantly in the air in households with
cats, these allergens are a potent source. Recent data
suggest that weekly washing of the cat, when com-
bined with other avoidance measures, greatly reduces
the allergen load into the house. Dog allergens are
found in saliva, skin dander and urine - not hair. Thus,
short-haired or long-haired breeds may be equally al-
lergenic. Cockroaches are another major allergen in
urban environments, which should be suspected in
any perennially allergic patient living in or around a
city. Commercial spraying is the only measure that
has been shown to reduce cockroach exposure.
Among the inhalant antigens, fungi occupy a
unique position because they are found in both out-
door and indoor environments. Alternaria and Cla-
dosporium are major outdoor allergens. Penicillium
and Aspergillus are the most prevalent molds found
in basements, bedding and damp interior areas. While
pollen allergens typically become wind-borne during
dry weather and are removed from the air during rain,
high mold-spore counts are found in clouds and mist.
Many upper respiratory tract allergy symptoms that
occur during periods of high humidity are probably
attributable to favorable conditions for mold growth.
When indoor mold exposures are considerable, install-
ing a dehumidifier in a damp area may be helpful. In
general, use of a bleach works as well as any other
product to remove fungi and mold in damp areas. The
pattern of allergen exposure in Arkansas is shown in
Table 1.
Allergic Rhinitis
Pathogenesis
Airborne foreign particles impact on respiratory
mucous membranes with each inhalation. Particulates
the size of most pollen grains and the larger mold
spores are deposited on the nasal mucosa. Only par-
ticles with an aerodynamic equivalent diameter of less
than 2 to 4 um are likely to reach the lower respiratory
82
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
tract. However, evidence indicates that in addition to
intact pollen grains themselves, pollen allergens are
airborne in much smaller particles and even particle-
free fractions of atmospheric moisture that potentially
can reach the lower respiratory tract. It is thought that
water-soluble allergens elute quickly from the antigen-
containing particle and diffuse into the respiratory
epithelium.
The nasal mucosa is enriched with a generous
supply of submucosal glands, including both serous
and mucous cells. Deep to the glandular tissue is a
plexus of sinusoids that may engorge to cause nasal
congestion. Just beneath the basement membrane is a
dense network of postcapillary venules, which is a
primary target for mast cell-derived mediators. The
nasal mucosa responds to acute allergic responses with
the following changes: increased vascular permeabil-
ity resulting in the formation of subepithelial edema
and the rapid production of albumin-rich secretions;
increased glandular secretions; and pruritus and sneez-
ing as reflex responses. This acute response is followed
by a chronic inflammatory response, including neu-
trophil and eosinophil infiltration of the mucosa, mast
cell hyperplasia (especially in the epithelium), increased
basophils and eosinophils in secretions, and activa-
tion (increased IL-2 receptor expression) of the rich
lymphocyte population located in the superficial lamina
propria. The inflamed mucosa becomes hyperresponsive
to both antigen and nonspecific irritants.
Histamine is thought to be the major mediator of
acute allergic responses (being capable of causing vas-
cular permeability, sneezing, pruritus and stimulating
reflex-mediated glandular secretions). The late-phase
allergic response is thought to be due to a combina-
tion of mast cell-derived inflammatory factors and
cytokines (possibly released by mast cells, lympho-
cytes or other inflammatory cells).
Clinical History
The patient's history is fundamental in the diag-
nostic evaluation of rhinitis. Symptoms may include
paroxysms of sneezing; itching of the nose, eyes, pal-
ate or pharynx; nasal stuffiness with partial or total
obstruction of airflow; and rhinorrhea often accompa-
nied by postnasal drainage. During peak symptom
periods, one or more of the following additional com-
plaints may be present; tearing and soreness of the
eyes coupled with a gelatinous conjunctival discharge
in the mornings, and loss of well-being with irritabil-
ity, fatigue and depression. Symptoms related to ac-
companying sinusitis or to eustachian tube dysfunc-
tion and serous otitis may also be present, particularly
in children. A personal history of other atopic diseases,
a strong family history of allergy or a regular seasonal
pattern of compatible symptoms is strongly sugges-
tive of an allergic cause. Although allergic rhinitis may
develop at any age, about 70% of patients develop
symptoms before the age of 30 years.
In assessing likely causative allergens, a detailed
history of when and where symptoms occur (and do
not occur) is of utmost importance. Correlation of
symptoms with allergens known to occur seasonally
in the patient's environment can provide important
diagnostic information. In perennial cases, temporal
relationships with the work week also may be reveal-
ing. The presence or absence of symptoms in various
locales may also provide good clues for this medical
detective exercise. Inquiry also should be made about
what things patients believe are causing their diffi-
culty. It is also of value to survey the patient's envi-
ronment with respect to exposure to various potential
allergens and currently used medications, especially
nose drops or sprays. Once symptoms have started,
they can be exacerbated by various nonspecific irri-
tants, such as cigarette smoke, strong odors, air pollu-
tion and climatic changes. Persistence of symptoms
beyond the pollen season may be due to the nasal
hyperresponsiveness, to superimposed hypersensitiv-
ity to perennial allergens, or to supervening infection.
Physical Findings
Positive physical findings during periods of acute
allergic rhinitis are limited to the nose, eyes and ears.
Occasionally, flaring of atopic dermatitis and, rarely,
urticaria may develop during the season of allergic
involvement. Rubbing the nose upward repeatedly in
childhood to "scratch an itchy nose" and to relieve an
obstructed nasal airway may cause a crease across the
lower part of the nose. Mouth breathing and infraor-
bital "shinners" (venous dilation of the skin beneath
the eyes) are common. Pale, bluish, edematous nasal
turbinates coated with thin, clear secretions are char-
acteristic. Nasal membrane swelling and accumulations
of clear mucus may obstruct the nasal airway and block
the sinus ostia leading to sinusitis. Tearing, scleral and
conjunctival injection and edema, and periorbital swell-
ing may be present. Fluid in the middle ear may lead
to decreased hearing with a dull, immobile tympanic
membrane on physical examination.
Laboratory Diagnostic Procedures
Despite the development of in vitro methods of
detecting IgE antibodies, skin testing (prick or intrad-
ermal) with appropriate allergens are the least time
consuming and least expensive studies, remaining the
most revealing tests for disclosing specific sensitivi-
ties. Skin testing can be performed on infants as young
as 1 to 4 months of age, although age dictates both the
choice of allergens used and the clinical conditions for
Volume 93, Number 2 - July 1996
83
which they can be used. In infants younger than 1
year, food antigens are the likely offenders, causing
eczema or anaphylaxis. Inhalant allergens are more
likely to be involved after 2 to 4 years of exposure,
although sensitization to indoor allergens can occur
much more quickly. In exceptional cases, such as in
patients with extensive eczema or marked dermogra-
phism that negates use of skin tests, in vitro or skin
tests, however, it is essential that the relevance of the
results to the patient's current clinical problems be
assessed in the light of the detailed history.
Since total IgE levels are elevated in only 30% or
50% of patients with allergic rhinitis and increased to-
tal IgE levels also occur in nonallergic conditions, an
elevated level does not make a diagnosis of allergy,
and a normal level does not rule it out. Thus, the clini-
cal value of determining total serum IgE levels is limited.
The peripheral eosinophil count may be elevated
in patients with allergic rhinitis, but this measurement
is also of limited usefulness. A smear of nasal secre-
tions for eosinophils is of more significance and is best
performed by having the patient blow his or her nose
onto a plastic sheet to collect the specimen and by
preparing the air-dried slide with Hansel's or Giemsa
stain for microscopic examination. A preponderance
of eosinophils suggests the diagnosis of allergic rhini-
tis, but this preponderance can also occur in cases of
eosinophilic nonallergic rhinitis. Considerable num-
bers of neutrophils are seen with viral or bacterial in-
fections and in rhinitis medicamentosa.
Complications
Serous Otitis Media - Serous otitis media can be a
complication of allergic rhinitis, especially in children.
It may result from obstructive dysfunction of the eus-
tachian tube as a result of mucosal edema and secre-
tions. However, in many instances of serous otitis
media, allergic factors cannot be identified. Sometimes
the process is acute and self-limited. When it is chronic,
it can lead to hearing loss with resultant adverse ef-
fects on speech development, cognition or both. The
young child is at greatest risk for these latter compli-
cations. Eustachian tube dysfunction makes the middle
ear more susceptible to recurrent infections, which in
turn may predispose it to less readily reversible mu-
coid effusions.
In treatment of patients with serous otitis media,
appropriate medications to keep the nasal airway patent
should be used. Therapy with antihistamines, decon-
gestants, topical steroids and antibiotics can be help-
ful in selected patients. When fluid and hearing loss
persist despite medical treatment, a myringotomy with
insertion of a tympanostomy tube will usually restore
hearing to normal while treatment is continued. Ob-
structing adenoid tissue may require surgical intervention.
84
Chronic sinusitis - In children, symptoms from
sinusitis include chronic nasal discharge, persistent
coughing (especially at night) and recurrent otitis me-
dia. Pain, headache and fever occur less frequently,
whereas in adults these along with purulent nasal dis-
charge are the most frequently recognized signs and
symptoms. The physician should consider diagnostic
studies for sinusitis whenever symptoms of upper res-
piratory tract infection or rhinitis are more protracted
than expected, the patient has dull to intense throb-
bing pain over the involved sinus area, the patient's
asthma is not responding appropriately to medications
or the patient has prolonged or persistent bronchitis
that has failed to respond to appropriate therapy. On
physical examination, edema and discoloration below
the eyes may be impressive. The nasal mucosa is in-
flamed and a purulent discharge frequently is seen on
the floor of the nose or beneath the middle turbinate.
Whenever sinusitis is diagnosed, the possibility of other
underlying processes should be considered.
Therapy
The treatment of patients with rhinitis is depen-
dent on the correct diagnosis. Three basic therapeutic
techniques should be considered in treating either sea-
sonal or perennial allergic rhinitis: (1) avoidance of the
offending allergens; (2) use of appropriate pharmaceu-
tical agents; and (3) allergy immunotherapy.
Allergen Avoidance - Whenever feasible, avoidance
is the preferred form of treatment since it both relieves
symptoms and eradicates the cause of the difficulty. It
is the only treatment necessary in most cases of al-
lergy to foods, drugs, animals and miscellaneous al-
lergens. Specific avoidance measures were discussed
in regards to specific allergens earlier.
Histamine Medications - H-1 antihistamines are
highly effective in controlling symptoms of nasal itch-
ing, rhinorrhea and sneezing and constitute the most
frequently used drugs for the treatment of allergic rhini-
tis. They act primarily as competitive inhibitors for
histamine at its H-1 receptor sites, but the older prod-
ucts also possess varying degrees of anticholinergic,
sedative, antiemetic and local anesthetic activity. The
newer, nonsedating antihistamines are generally more
selective in their actions. Nasal congestion is less re-
sponsive to antihistamines than sneezing, itching, rhi-
norrhea and eye symptoms.
On the basis of chemical structure, the commonly
used antihistamines have been classified into six groups
(see table 2). In addition, numerous combined anti-
histamine-decongestant preparations are available.
Patients responding inadequately to an antihistamine
of one group may have a good response to a drug
from another group.
A major limitation to the use of older antihistamines is
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Class
Table 2
Antihistamine Classification
Nonproprietarv Name
Trade Name
Ethanolamine
Diphenhydramine hydrochloride
Benadryl
Alkylamines
Chlorpheniramine maleate
Chlor-trimeton
Brompheniramine maleate
Dimetane
Piperazines
Hydroxyzine hydrochloride
Atarax
Cetirizine
Zyrtec
Phenothiazines
Promethazine hydrochloride
Phenergan
Piperdines
Azatidine maleate
Optimine
Miscellaneous
Cyproheptadine hydrochloride
Periactin
Clemastine fumerate
Tavist
Nonsedating antihistamines
Terfenadine
Seldane
Astemizole
Hismanal
Loratadine
Claritin
sedation and excessive mucosal drying. Because of the
latter, they have been considered undesirable in pa-
tients who have both asthma and allergic rhinitis.
However, recent evidence has demonstrated they can
be used safely in patients with asthma. A new genera-
tion of H-1 antihistamines has been developed that is
devoid of these problems. Examples are astemizole,
terfenadine, loratadine and cetirizine.
Patients should start receiving antihistamines be-
fore the allergy season begins or when they become
symptomatic. The rule of thumb is to use the smallest
dose of product that is effective. Because of their ef-
fectiveness and wide acceptance, the nonsedating an-
tihistamines are the agents of choice. If cost limitation
is essential, use of a relatively nonsedating classic anti-
histamine (such as chlorpheriirarnine maleate) can be used.
A variety of nose drops and nasal sprays that con-
tain alpha adrenergic agonists are available for tempo-
rary relief of congestion. The most common topical
preparations are phenylephrine hydrochloride, a short-
acting agent, and two longer-acting decongestants -
oxymetazoline hydrochloride and xylometazoline hy-
drochloride. Although topical therapy avoids systemic
effects, prolonged therapy (more than 3 or 4 days of
use) may result in progressively more severe nasal
obstruction due to a rebound recongestion (rhinitis
medicamentosa). Accordingly, these preparations are
contraindicated for long term use.
Topical cromolyn sodium is useful in allergic rhini-
tis. Its effects are best seen when used prophylactically and
are of short duration; therefore, it must be adminis-
tered 2 to 4 times a day regularly. Cromolyn is some-
what less potent than topical steroids but is essen-
tially devoid of side effects. It also is marketed as a 4%
ophthalmic solution that may be used in treating pa-
tients with allergic conjunctivitis and giant papillary
conjunctivitis.
The usefulness of topical steroids for the treatment
of allergic rhinitis has been long recognized. Several
potent and rapidly metabolized products
(beclomethasone, flunisolide, triamcinolone, fluticizone
and budesonide) when applied intranassally are effec-
tive in the treatment of allergic rhinitis and lack sig-
nificant systemic effects. Local burning, irritation and
occasional epistaxis are the most common side effects.
There has been no evidence of mucosal atrophy and
pharyngeal candidiasis has not been a problem. Nasal
septal perforation does occur rarely with topical ste-
roid use, especially when the patient discharges the
medication onto the septum. Care in instructing the
patient to deliver the spray away from the septum is
useful in preventing this problem. Perforations, should
they occur, are anterior and of cosmetic importance only.
Topical nasal steroids reduce the irritation, sneez-
ing, itching, congestion and rhinorrhea of allergic rhini-
tis, especially when used with antihistamines. They
fail to relieve ocular symptoms (which attests to the
lack of systemic effects). They also have a role in the
therapy for perennial allergic rhinitis, nonallergic rhini-
tis with eosinophilia syndrome and nasal polyps. In
Volume 93, Number 2 - July 1996
85
addition, they can be helpful in weaning patients with
rhinitis medicatmentosa from vasoconstrictor agents.
Immunotherapy for Allergic Rhinitis
Immunotherapy (hyposensitization) is a method
employing subcutaneous injections of gradually in-
creasing doses of antigenic (allergenic) materials for
the purpose of altering the immunologic response of
atopic patients. Since its initial introduction in 1911,
multiple, controlled clinical investigations of the re-
sponse to extract therapy have been done. Many stud-
ies have shown that immunotherapy, especially with
large doses of antigen, benefits patients with seasonal
and perennial allergic rhinitis, as well as allergic
asthma. Immunotherapy has been most successful for
the treatment of allergic rhinitis caused by pollens,
animal dander and dust mites. The efficacy of immu-
notherapy for eczema, food allergy or urticaria has not
been established.
Allergenic extracts used for immunotherapy are
prepared from a variety of sources including pollens,
epidermals, molds and insect venom. Once made, al-
lergic extracts should be refrigerated whenever pos-
sible to prevent protein degradation of the extract.
Treatment schedules vary among individuals, but the
average patient can usually begin with doses of ap-
proximately 1:100,000 dilution. Injections are given in
increasing doses as tolerated every 3 to 7 days towards
a maintenance dose, which may also vary according
to individual needs.
Maximal clinical benefit from immunotherapy usu-
ally occurs within 12-24 months after reaching adequate
maintenance doses. Continuation of treatment depends
on the response of each patient. The average patient
usually receives 3-5 years of therapy. At present, there
are no measurements that can accurately predict the
probability of clinical relapse after discontinuing im-
munotherapy. A practical approach is to continue in-
jections every 4-6 weeks for 1-2 symptom-free years
and then discontinue.
Overall Treatment Plan for Allergic Rhinitis
Patients should be evaluated for specific allergen
sensitivity by a careful history, confirmed by skin test-
ing. Avoidance of incriminated allergens is the first
line of therapy. Most patients will respond to a combi-
nation of antihistamine and topical nasal steroid with
a rapid reduction in symptoms. Cromolyn is an ac-
ceptable alternative, either alone or combined with an
antihistamine. Allergy immunotherapy should be con-
sidered in patients with pollen, animal or dust mite
allergies who are not responding adequately to phar-
macotherapy, who require medications more than 6
months of the year or who develop complications from
the pharmacotherapy.
86
References:
1. Druce HD: Allergic and non-allergic rhinitis. In Middleton
E Jr., Reed CE, Ellis EF et al, editors: Allergy: principles and
practice, ed 4, Mosby, St. Louis, 1993:1433-51.
2. Kaliner M, Lemanski R: Rhinitis and Asthma. In Lockey
RF, editor: Primer on Allergic and Immunologic Diseases,
JAMA 268:2807, 1992.
3. Fieri MB: Allergies of the upper respiratory tract in Lawlor
GJ, Fischer TJ, and Adelman DC, editors: Manual of Allergy
and Immunology, ed 3, Little, Brown and Co., 1995.
4. Platts-Mills TAE, Chapman M.D.: Dust Mites: Immunol-
ogy, allergic disease, and environmental control. J Allergy
Clin Immunol 80:755, 1987.
5. DeBlay F, Chapman M.D., Platts-Mills TAE: Airborne CAt
Allergen (Fel d I): Environmental control with the cat in situ.
Am Rev Respir Dis 143:1334, 1991.
6. Creticos PS, Norman PS: Immunotherapy with allergens.
JAMA. 258:2874-2880, 1987.
7. Weber RW, Nelson HS: Pollen allergens and their interre-
lationships. Clin Rev Allergy. 3:291-318, 1985.
8. Meltzer EO, Schatz M: Pharmacotherapy of rhinitis - 1987
and beyond. Immunol Allergy Clin North Am 7:57, 1987.
9. Norman PS: Allergic rhinitis. J Allergy Clin Immunol
75:531, 1985.
10. Mygind N: Nasal allergy. Ed 2, Oxford, Blackwell. 1979.
11. Creticos PA, editor: Immunotherapy: A practical guide
to current procedures. Miles Inc., 1994.
SPECIAL NOTICE:
The AMS' P.O. Box
Number Changes...
As of My 15, 1996, the
Arkansas Medical Society's
post office box address will be:
P.O. Box 55088
Little Rock, AR 72215-5088
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
1 TURN TO THE SPECIALISTS FOR A |
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• Policies that can’t be
associations, Paul Revere’s
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you should you relocate.
includes:
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• A 15% discount off each
compare? For a no-obligation
year’s premium
examination of your current
•A full line of policies to pro-
disability insurance plan,
tect you and your practice
call us today.
Alanna S. Scheffer
Arkansas Medical Society
RO. Box 5776
Little Rock, AR 72215-5776
Tel: (501)224-8967
(800) 542-1058
Fax: (501) 224-6489
Agent: Beth A. Perry Paul Revere Life ^
Insurance Company wm.
Arkansas Medical Society Presents Workshops
CPT & iCD-9
For Physicians & Medical Office Staff
CPT - General Surgery
Little Rock - July 18
Jonesboro - August 30
Springdale - October 3
El Dorado - October 17
Watch for registration materials to be mailed or contact the AMS
office at (501)224-8967 or 1-800-542-1058 for more information.
CPT for Family Practice
& Internal Medicine
Little Rock - July 16
Jonesboro - August 28
Springdale - October 1
El Dorado - October 15
ICD - for AW Specialties
Little Rock - July 17
Jonesboro- August 29
Springdale - October 2
El Dorado - October 16
THE NUMBER 1 REASON YOUR PATIENTS
WILL HAVE A MAMMOBRAM THIS YEAR.
mm
No matter what your specialty, the American Cancer Society needs you to recommend an
annual mammogram for every woman over 50. An annual mammogram is critical for early
detection and intervention, yet too many women are not hearing this message.
Take the first step. Call 1-800- ACS-2345 for information that can help you make an impact.
APublicSarviMof
Thi* Pubileation
nitMHMQIiMIIII
EVERY YEAR AETER 50
I.
AAAERICAN
^CANCEIi
?SOaETY
88
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Cardiology Commentary and Update
Mark St. Pierre, M.D.*
J. David Talley, M.D.*
PRIMARY PREVENTION OF CORONARY ARTERY DISEASE
Atherosclerotic coronary artery disease (CAD) and
its associated myocardial manifestations (coronary heart
disease, CHD) is the leading cause of death and dis-
ability in the United States. CHD is responsible for
more than 50% of all cardiovascular deaths and one of
every four deaths. Nearly 1.5 million Americans sus-
tain an acute myocardial infarction (MI) annually, and
of these, 500,000 die. CHD is also the leading cause of
premature, permanent disability in the U.S. labor force
and accounts for 20% of disability allowances by the
Social Security Administration. In 1989, CHD was re-
sponsible for $22 billion in direct and $32 billion in
indirect economic costs.’ CHD is a major public health
problem and simple preventive strategies offer the
promise of reducing mortality and morbidity.
This review will focus on preventing CAD and
CHD by modifying hypercholesteremia, cigarette
smoking, systemic arterial hypertension, and diabetes
mellitus. In addition, the benefits of moderate alcohol
consumption, aspirin (ASA) use, estrogen replacement
therapy in postmenopausal women, exercise, and obe-
sity will be discussed.
Hypercholesterol
The World Health Organization Cooperative Trial
evaluated the effect of clofibrate on more than 10,000
middle-aged men (30 to 59 years old) who had a high
total cholesterol.^ During the 5 year follow-up period,
patients receiving clofibrate had a 9% reduction in se-
rum cholesterol, 25% risk reduction in developing
non-fa tal MI, and a 20% decrease in risk of developing
CHD. CHD mortality was not reduced, and total mor-
tality was paradoxically increased due to an increase
in gastrointestinal cancer. This association between low
levels of cholesterol and gastrointestinal cancers has
not been confirmed by other trials.
The Lipid Research Clinic Coronary Primary Pre-
vention Trial (LRC-CPPT) reported that decreasing
cholesterol reduces the occurrence of future CHD
* Drs. St. Pierre and Talley are members of the Division of
Cardiology, Department of Internal Medicine, UAMS
Medical Center.
events.^ More than 3800 men with a total cholesterol
greater than 265 mg/dl and low density lipoprotein
subtraction (LDL) more than 175 mg/dl, without sys-
temic arterial hypertension, hypertriglyceridemia or
diabetes mellitus were enrolled. They were random-
ized to receive diet therapy alone or the bile acid
sequestrant, cholestyramine, during the study period
of 7.4 years. While the recommended dose of
cholestyramine was 24 grams/day, the average dose
was 14 grams/day.
By itself, diet treatment decreased the total cho-
lesterol 5% and LDL cholesterol by 8%. Patients treated
with cholestyramine had a 12% reduction in total cho-
lesterol and 19% decrease in LDL cholesterol.
Cholestyramine reduced the risk of non-fatal MI by
19%, cardiovascular deaths by 24%, angina by 20%,
newly positive exercise test by 25%, and coronary ar-
tery bypass graft surgery by 21%. Total mortality was
not different between the two groups, despite the de-
cline in cardiovascular deaths. Patients treated with
cholestyramine had a higher level of mortality from
non-cardiovascular causes, particularly motor vehicle
accidents and other forms of violent death. These per-
plexing results appear to be due to a statistical quirk
unrelated to any pathological effect of cholestyramine
or cholesterol lowering. The findings of LRC-CPPT
provided strong support in favor of the lipid hypoth-
esis for coronary atherosclerosis and established that a
1% decrease in total cholesterol is associated with a
2% reduction in CHD event rate.
In the Helsinki Heart Study, 4081 middle-aged men
without known CHD but an elevated non-HDL cho-
lesterol ( > 200 mg/dl), were randomized to receive
either gemfibrozil or placebo.'' Patients with elevated
triglycerides were included. During the 5-year
follow-up period, the gemfibrozil group had 10% re-
duction in total cholesterol, and a 35% reduction in
triglycerides. These favorable results were accompa-
nied by a 34% reduction of cardiovascular death or
non-fatal ML An increased HDL level was the stron-
gest predictor of reduction in CHD events. Patients
with a ratio of LDL to HDL >5, showed the greatest
Volume 93, Number 2 - July 1996
89
benefit of treatment with gemfibrozil, resulting in a
71% reduction in CHD event rate. These findings pro-
vided a strong support of the role of low HDL choles-
terol levels to promote the development of CHD.
Finally, the results of the West of Scotland Coro-
nary Prevention Study were recently published.'’ This
study demonstrated that the use of pravastatin, in
assymptomic men without prior MI, reduced total
cholesterol by 25%, and the relative risk of non-fatal
Ml or death from CHD by 31%. This benefit was evi-
dent by 6 months after beginning treatment and in-
creased during the 5 year follow-up period. There was
a 22% reduction in death from any cause and there
were no excess deaths from non-cardiovascular causes
in the pravastatin group unlike previously reported
studies.
Smoking Cessation
The magnitude of risk associated with cigarette
smoking is similar to that of systemic arterial hyper-
tension and hypercholesterolemia, however, because
cigarette smoking is present in a greater proportion of
the population, it ranks as the largest preventable cause
of CAD. Smoking is associated with 30% of CHD deaths
annually in the U.S. Current smokers have 2 to 4 times
the risk of CHD compared with nonsmokers. ^ There
is a strong dose-response relationship between the
number of cigarettes smoked and the relative risk of
fatal CHD in both males and females.
The Surgeon General's report in 1989 noted that
cigarette smoking doubles the incidence of CAD and
increases mortality from CHD from 50 to 70%. The
three randomized cessation trials decreased cardiac
events from 7 to 47%. These trials did not include pa-
tients with CAD.
The risk of MI declines rapidly within several
months after stopping smoking. Stopping smoking
reduces risk of CHD by 50% within one year, and
within two to three years the risk of MI is similar to
those individuals who had never smoked.^ This im-
provement may be due to the reversible prothrombotic
effects of cigarette smoke including a decrease in fi-
brinogen and platelet adhesion. Other beneficial ef-
fects of stopping smoking include a reduction of car-
boxyhemoglobin and an increase in HDL cholesterol.
Patients need to be motivated to stop smoking,
especially after a cardiac event. Nurse-managed smok-
ing cessation program decrease smoking rates to less
than 1/2 in patients who previously smoked. These
programs address psychological and behavioral depen-
dency on smoking and offer nicotine replacement
therapy to reduce the symptoms of withdrawal and
improve cessation rates.
Systemic Arterial Hypertension
Systemic arterial hypertension doubles the risk of
developing CHD. It is present in one-third of the U.S.
adult population. Primary prevention trials using di-
uretics and beta-blockers showed a 20-fold reduction
90
in mortality from all vascular causes, 40-fold reduction
in stroke, and nearly a 1 5-fold reduction in MI.®
Diabetes Mellitus
Diabetes mellitus increases the risk for CHD 2 to 3
times in men and 3 to 7 times in women. Diabetes
mellitus negates the cardioprotective benefit of pre-
menopausal women. Atherosclerosis accounts for 80%
of all diabetic mortality. Although one would expect
that improved glucose control would reduce the risk
of CHD, this was not demonstrated in the University
Group Diabetes Program, the only large-scale clinical
trial able to study cardiovascular end points. There
have been no clinical trials designed specifically to test
whether glucose control will prevent macrovascular
(atherosclerotic) complications of diabetics. However,
from the Diabetic Control and Complication Trial, re-
sults indicate that improved glucose control reduces
the microvascular complications of insulin dependent
diabetes mellitus.
Ethanol Use
There is a clear correlation between moderate etha-
nol intake and decreased levels of CAD. The protec-
tive effects of ethanol are secondary to increased lev-
els of HDL cholesterol, particularly subfractions HDL2
and HDL3, both of which are inversely related to the
risk of myocardial infarction.® Recently, however,
modest doses of ethanol have been found to have an
acute effect on the coagulation system by inhibiting
plasminogen activator inhibitor-1.
Several studies have shown an inverse association
between moderate alcohol consumption and the risk
of ML The Framingham Study found a 30% reduction
in risk among men and women who consumed 30
grams of alcohol per month. The Honolulu Heart Study
reported 54% risk reduction in men who consumed 40
ml of alcohol a day. And the Nurse's Health Study
observed a 40% reduction in risk among women who
consumed 10-15 grams of alcohol a day, as compared
to nondrinkers. The quantity of alcohol is roughly
equivalent to 1 ounce of hard liquor, 12 oz. of beer, or
4 oz. of wine. Most researchers have concluded that
alcohol intake should be limited to one to two drinks a
day for men, and one drink a day for women.
Aspirin
Two randomized trials have evaluated the use of
aspirin as primary prevention of CHD. The U.S. Phy-
sicians Health Study randomized 22,000 male physi-
cians to ASA (325 mg) or placebo.’® The 5-year study
was stopped because of a 44% reduction in non-fatal
ML The benefit was seen mainly in men over 50 years
of age. There was no difference in total or cardiovas-
cular mortality. The ASA treated group had a higher
incidence of hemorrhagic stroke (0.2 vs. 0.1 %) and a
significant increase in hemorrhage from the gastrointes-
tinal tract (0.5% vs. 0.3%).
The British Doctors Trial included 5,000 male physi-
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
dans.” Two-thirds were randomized to ASA (500 mg/
day) compared to 1/3 who received placebo. After 6
years, there was no difference in MI or cardiovascular
death in the two groups.
Meta-analysis of these two studies indicates ASA
reduces the risk of a first non-fatal MI by 32%. The
absolute risk reduction is quite small (two events per
1,000 patient/yr.) because the prevalence of cardiovas-
cular events was low among the physician in these
two studies. Therefore, the U.S. Prevention Services
Task Force recommends ASA for men over the age of
40 who are at risk for MI.
Estrogen Replacement Therapy
Premenopausal women are relatively protected
from CHD compared to similarly aged males. From
the Framingham Study, the risk of CHD increases dra-
matically in postmenopausal women. An overview of
31 observational studies reported that CHD was re-
duced by 44% in postmenopausal females treated with
estrogen. The risk of breast cancer was 1 .3 for estro-
gen alone and 1.4 for estrogen plus progesterone.
The Postmenopausal Estrogen/Progesterone Trial
was a three-year study of 875 postmenopausal women
who received placebo, estrogen, or three different es-
trogen/progesterone combination regimens comparing
the effects on HDL, LDL, fibrinogen and blood pres-
sure.” Estrogen and combination therapy increased
HDL, lowered LDL and fibrinogen and had little ef-
fect on systemic blood pressure. Estrogen without
progesterone increased HDL, but increased the inci-
dence of endometrial hyperplasia. Females at high risk
for developing CAD should receive estrogen alone or
combined with progestin. Physicians should monitor
for harmful side effects, especially endometrial hyper-
plasia.
Exercise
Exercise lowers systemic arterial blood pressure
and heart rate, the two major determinants of myo-
cardial oxygen demand. Physical exercise also increases
HDL, decreases platelet adhesiveness and the adren-
ergic response to stress. Physical inactivity doubles
the risk of dying from CHD. The American Heart As-
sociation recommends 30 minutes, three to four times
per week of moderate intensity exercise. This is equal
to burning 200 calories or walking two miles briskly.
Approximately 80% of adults do not meet this guideline.
Obesity
Obesity is defined as >20% of ideal body weight,
and affects one-third of the U.S. adults. Obesity is as-
sociated with other CAD risk factors including sys-
temic arterial hypertension, glucose intolerance and
decreased HDL cholesterol. Most of the CAD risk from
obesity is mediated by their associations. No study
has specifically examined the effect of weight loss on
CHD, however, observational studies have noted that
avoidance of obesity is reduces the risk of MI by 35 to
55%. Also the role of weight reduction in the treat-
ment of systemic arterial hypertension, dyslipidemia
and diabetes makes it an obvious choice for intervention.
Conclusions
Risk factors which promote the development of
CAD include hypercholesterolemia, systemic arterial
hypertension, cigarette use, and diabetes mellitus.
Patients need to be informed and counseled on the
value of modifying these conditions.
References:
1. Kannel WB, Thom TJ: Incidence, prevalence and mortal-
ity of cardiovascular diseases. In The Heart 8th ed. (Eds.
Schlant RC, Alexander RW). NY: McGraw-Hill, 1994:185-197.
2. Committee of Principle Investigators: WHO Cooperative
Trial on primary prevention of ischemic heart disease with
clofibrate to lower serum cholesterol: Final Mortality
follow-up. Lancet 1984;2:600-604.
3. Lipid Research Clinics Program: The Lipid Research Clin-
ics Coronary Primary Prevention Trial results. The relation-
ship of reduction in incidence of coronary heart disease to
cholesterol lowering. JAMA 984;251:365-374.
4. Manninen V, Tenkanen L, Koskinen P, et al: Joint effects
of serum triglyceride and LDL cholesterol and HDL choles-
terol concentrations on coronary heart disease risk in the
Helsinki Heart Study. Implications for treatment. Or. 1992;85:37-45.
5. Shepherd J, Cobbe SM, Ford I, et al: Prevention of Coro-
nary Heart Disease with Pravastatin in men with hypercho-
lesterolemia. N Engl J Med 1995;333: 1301-1307.
6. Jones MA, Oates JA, Ockene JK, Hennekens CH: State-
ment on smoking and cardiovascular disease for health care
professionals. AHA Medical/Scientific Statement, Position
Statement. Circulation 1992;86:1664-1669.
7. Rosenberg L, Kaufman DW, Helmrich SP, Shapiro S: The
risk of myocardial infarction after quitting smoking in men
under 55 years of age. N Engl J Med 1985;313:1511-1514.
8. Collin R, Peto R, MacMahon S, et al: Blood pressure, stroke
and coronary heart disease: part 2, short term reductions in
blood pressure: overview of randomized trials in their epi-
demiologic context. Lancet 1990;335:827-838.
9. Thornton J, Symes C, Heaton K: Moderate alcohol intake
reduces bile cholesterol saturation and raised HDL choles-
terol. Lancet 1983;2:819-822.
10. Steering Committee of the Physicians Health Study Re-
search Group. Preliminary report: Findings from the aspirin
components of the ongoing Physicians Health Study. N Engl
J Med 1988; 318 :262-264.
11. Petro R, Gray R, CoUins R, et al: Randomized trial of prophy-
lactic daily aspirin in British male doctors. Br Med 296:313-316,
1988.
12. Stampfer MJ, Colditz GA Estrogen replacement therapy
and coronary heart disease: a quantitative assessment of the
epidemiologic evidence. Prev Med 1991;20:4763.
13. Stampfer MS, Colditz GA, Willett WC, et al: Postmeno-
pausal estrogen therapy end Cardiovascular Disease: ten year,
for follow-up from the Nurses' Health Study. N Engl J Med
1991;325:756-762.
14. Writing Group for the PEPI Trial: Effects of Estrogen or
Estrogen/Progesterin Regimens on heart disease risk factors
in post menopausal women: The Postmenopausal Estrogen/
Progestin Interventions (PEPI) Trial. JAMA 1995;273: 199-208.
Volume 93, Number 2 - July 1996
91
SOUTH DAKOTA PHEASANT HUNTING
with James R. Weber, M.D.
The Best Wild Pheasant Hunting in America
Make Reservations Now
I have never seen so many wild pheasants at one time. Over 1,000 pheasants were killed last year. We
can’t guarantee you will get your limit each day, but we do guarantee you will have ample chance to do
so. We book groups of 2 to 12 hunters per day with a three-day minimum. You will see hundreds of
birds each day on some of the finest habitat available consisting of 2,500 acres of food plots and crop
land. This land is farmed strictly for pheasant production. The location is near Mitchell, SD.
Season - October 19 through December
License cost - $65.00
Daily Limit - 3 Cock Pheasants
Possession - 15
Guiding Cost - $175.00 Per Hunter Per Day
Down payment $50.00 Per Hunter Per Day
Package Deal with Hotel Room for 3 is Available
Make reservations today by calling
Specialty Outfitters (501)985-0744.
THESE HUNTS FILL QUICKLY
Do the
' Write
Thing!
We're always looking for interesting and infor-
mative articles for The Journal. If you have a
topic that you think would be of interest to your
peers, please submit it for consideration to:
Managing Editor
The Journal of the Arkansas Medical Society
P.O. Box 55088
Little Rock, AR 72215-5088
(501)224-8967 (800)542-1058
ATTENTION
PHYSICIANS
The Arkansas Medical Society 1996
Membership Directory - a valuable source for
physicians, clinics and other health care
professionals and businesses - will be available in
August. The directory lists all AMS members by
city with their address, phone and fax numbers and
specialty. The directory also contains information
such as the dates of AMS and AMA meetings,
county executives and specialty societies. All
AMS members will automatically receive one
directory through the mail at no charge.
Businesses, clinics and other health care
organizations may purchase the directory for $50.
Call (501)224-8967 for rates on larger quantities.
To order, send a check or money order to: Arkan-
sas Medical Society, 1996 Directory, P.O. Box
55088, Little Rock, AR 72215-5088.
92
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
StAtc \kskh W^tcl
1
Information provided by the Arkansas Department of Health, Division of Epidemiology
Management of Animal Bites
All individuals bitten by an animal should be evalu-
ated by their physician as to the need for treatment
and rabies prophylaxis. Prophylaxis may be deferred
if the biting animal is a dog or cat, and is available for
quarantine. This is possible since a dog or cat infected
with rabies will become symptomatic and die within
10 days. If the dog or cat remains healthy for 10 days,
prophylaxis is unnecessary. There is no reliable quar-
antine period for wildlife, since many animals may
carry and transmit rabies virus in the absence of symp-
toms. Animals other than dogs or cats must be sacri-
ficed and the head submitted to the Arkansas Depart-
ment of Health (ADH) Laboratory for fluorescent anti-
body (FA) testing. A negative FA test is evidence that
rabies virus is not present in the brain and saliva and
eliminates the necessity for post exposure treatment.
The ADH is open 24 hours a day to receive specimens.
All practicing veterinarians and county health units
have insulated shipping containers and will assist in
the proper packing and shipping of rabies suspect heads.
The Veterinary Public Health Office in the ADH
provides consultation on the necessity for post expo-
sure rabies treatment for all animal bites. Vaccine is
stocked at the ADH pharmacy and will be released to
physicians on request. Phone Dr. Tom McChesney
for consultation or vaccine requests. Office #661-2597;
Home #982-5697.
Deliveries of rabies vaccine are made by United
Parcel Service or commercial bus or air, whichever will
provide the most timely service.
Treatment with the current Human Diploid Cell
Vaccine (HDCV) requires five 1-ml. injections in the
deltoid muscle on days 0, 3, 7, 14 and 28. The vaccine
is lyophilized, and each vial is recombined with one
ml. of diluent immediately prior to injection. Human
Rabies Immune Globulin (HRIG) is given on the first
day of treatment at the rate of two ml. per 33 pounds
of body weight. If the bite is in a fleshy part of the
body, half of the HRIG should be infiltrated around
the wound. HRIG furnishes immediate antibody pro-
tection and may be the most important part of the
treatment.
During 1995, approximately 150 Arkansans were
administered post-exposure treatment after being bitten by
a rabid or suspected rabid animal. There have been
no serious systemic or neuroparalytic reactions to
HDCV, although about 20% of the patients report
erythema, pain, swelling or itching at the injection site.
Serologic testing is no longer necessary except in those
patients whose immune response may be compro-
mised. Protective antibody levels were developed by
99.9% (1299 of 1300) persons tested.
Rabies Update
Since 1960, rabies in the United States has been
more frequently reported in wild animals than in do-
mestic animals. From 1990 to 1994, rabies in wild ani-
mals accounted for almost 92% of all cases reported to
the Centers for Disease Control and Prevention (CDC).
The most frequently reported rabid wild animals in
order of prevalence are raccoons, skunks, bats and
foxes. Raccoon rabies predominates in the Northeast,
Southeast and Mid-Atlantic states. (Only two (2) rac-
coons have been positive for rabies in Arkansas, one
in 1987 and one in 1992. Both were infected with the
skunk strain of rabies virus.) Skunk rabies predomi-
nates in the Central and Western states. During 1995,
fifty-two (52) animals were identified as being rabid in
Arkansas. The two most frequently reported were
Volume 93, Number 2 - July 1996
93
skunks (38) and bats (five) (See chart 1). About 50% of
the skunks and 10% of the bats tested in the Arkansas
Department of Health laboratory are rabid. These
animals are submitted to the laboratory because of bi-
zarre behavior or because they have bitten another
animal or a human.
In the United States, the number of cases of indig-
enous human rabies reported over the past thirty years
has averaged only 1.17 cases per year. In the past two
decades, rabies virus variants associated with bat res-
ervoirs have been responsible for the largest number
of human cases.
There were six cases of rabies reported in humans
in 1994 and three additional cases in 1995. This brought
the total cases of human rabies in the United States
from 1980-1995 to twenty-eight. Seventeen of these
individuals were infected with variants associated with
animal reservoirs in the United States. Monoclonal
antibody analysis, genetic sequencing, or exposure
history indicated that 15 of the 17 people were infected
with variants associated with rabies in bats. Ten (10)
of the virus variants obtained from these 15 persons
have been characterized as a silver-haired bat variant.
Although numbers remain small, the possibility of
infection of human beings with a rabies virus from
bats is a public health concern.’
There have been only two human rabies deaths in
Arkansas residents in the past forty years. The last
case, in 1991, occurred in a twenty-nine-year-old man
from Clark County. He did not give a history of being
bitten by an animal and had never traveled beyond
the southwest region of the state during his lifetime.
Post mortem samples of brain tissue were positive for
rabies by direct fluorescent antibody testing. Mono-
clonal antibody typing suggested that the rabies vari-
ant was that commonly found in silver-haired bats.
The patient lived alone in a previously abandoned ru-
ral home. His girlfriend reportedly witnessed an inci-
dent in the home approximately a month prior to on-
set of symptoms, when a bat landed on his face and
possibly bit or scratched him. The patient failed to
notify the Health Department of the bite or send the
bat to the ADH laboratory for rabies testing.^
The three U.S. cases of human rabies reported for
1995 were all caused by bat rabies variants. One of
these cases occurred in a four year old female in Wash-
ington State who died of rabies in March of 1995. The
family had found a bat in her bedroom one month
prior to her onset of illness, but no bite was reported
or seen. The bat had been buried, but was exhumed
and tested for rabies. It was found to be positive and
the virus strain was identical in both the patient and
the bat.”
It was mentioned previously that fifteen of the
twenty-eight cases of human rabies that have been
reported since 1980 had been caused by bat strains of
the virus. Of this number, only six had a clear history
of animal bite exposure. This finding suggests that
even limited contact with bats infected with rabies may
be associated with transmission. Cases reported show
that in situations in which a bat is physically present
and the persons cannot exclude the possibility of a
bite, post exposure treatment should be considered
unless prompt testing of the bat has ruled out rabies
infection. This recommendation should be used in
conjunction with guidelines of the Advisory Commit-
tee on Immunization Practices.'’
Footnotes:
1. Krebs JW, Strine TW, Smith JS, et al. Rabies Surveillance
in the United States during 1994. Public Veterinary Medi-
cine 1995; 207(12): 1562-1575.
2. Human Rabies Cases Case in Arkansas. Arkansas
Physician's Bulletin 1991.
3. Human Rabies - Washington, 1995. MMWR 1995; 44:625-627.
4. ACIP, Rabies Prevention - United States, 1991: Recom-
mendations of the ACIP. MMWR 1991. 40(RR-3).
94 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reported Cases of Selected Reportable Diseases in Arkansas
Profile for April 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
April 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1995
Total
Reported
Cases
1994
Campylobacteriosis
17
47
40
28
152
187
Giardiasis
8
38
34
29
131
126
Shigeilosis
6
25
35
46
175
193
Salmonellosis
22
71
52
56
332
534
Hepatitis A
41
195
82
34
663
253
Hepatitis B
1
30
26
16
92
60
HIB
0
0
4
2
6
5
Meningococcal Infections
3
18
20
26
39
55
Viral Meningitis
3
11
5
9
31
62
Lyme Disease
1
5
3
5
9
15
Rocky Mountain Spotted Fever
1
2
3
3
30
18
Tularemia
1
2
2
6
22
23
Measles
0
0
2
1
2
5
Mumps
0
0
4
3
5
7
Rubella
0
0
0
0
0
0
Gonorrhea
423
1632
1536
1914
5437
7078
Syphilis
74
312
334
342
1017
1096
Legionellosis
0
0
5
4
5
16
Pertussis
0
2
12
17
60
33
Tuberculosis
30
62
71
63
271
264
Volume 93, Number 2 - July 1996
95
Arkansas HIV/AIDS Report
1983-1996
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include;
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: County of residence may
change from date of HIV test to date
of AIDS diagnosis.
HIV
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total ?
%
1
Male
100
215
248
413
400
392
352
367
337
136
2,960
83
X
Female
8
26
37
68
85
81
94
90
92
42
623
17
Under 5
1
1
2
8
13
6
3
7
2
1
1
5-12
0
1
1
5
1
2
1
0
1
0
12
0
13-19
0
7
8
14
19
25
11
22
12
16
134
4
20-24
12
40
52
71
44
49
64
60
47
15
454
13
25-29
21
70
71
112
105
107
111
85
78
39
799
22
A
30-34
25
50
64
116
120
111
91
102
101
28
808
23
G
35-39
19
36
40
80
88
68
77
69
81
37
595
17
B:
40-44
16
17
17
43
50
41
47
50
46
18
345
10
45-49
6
8
18
13
20
26
18
27
24
7
167
5
50-54
2
1
5
8
14
14
10
12
17
7
90
3
55-59
1
3
4
6
3
13
6
7
5
6
54
2
60-64
' 1
0
1
1
2
6
5
9
8
1
34
1
65 and older
4
2
1
2
3
5
2
7
7
3
36
. 1
R
White
87
170
174
328
298
293
278
259
260
87
2,234
62
A
Black
21
69
108
151
184
173
163
184
159
79
1,291
36
C
Hispanic
0
1
3
1
3
4
1
7
3
2
25
1
E
Other/Unknown
0
1
0
1
0
3
4
7
7
10
33
1
Male/Male Sex
64
137
140
243
246
261
242
229
157
49
1,768
49
Injection Drug User (IDU)
13
30
48
74
96
75
65
71
50
8
530
15
R
Male/Male Sex & IDU
19
23
24
32
30
34
26
23
25
8
244
7
1
Heterosexual (Known Risk)
5
25
26
59
64
68
100
94
56
17
514
14
s
Transfusion
5
5
4
6
8
10
0
2
2
0
42
1
K
Perinatal
1
1
2
8
13
8
4
7
0
0
44
1
Hemophiliac
0
0
6
18
5
6
2
3
5
0
45
1
Undetermined
1
20
35
41
23
11
7
28
134
96
396
11
HiV CASES BYYEAR
108
481
1485'^:
473
446
457
429
178
3,583
100
HIV In
Arkansas
H1V+ CASES
REPORTED
□
1 to 3
□
4 to 49
□
50 to 99
■
100 to 1260
I County of residence at the time of test for the 3,583 Arkansans reported to be HIV+. (5/12/96)1
96
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1996
iiFultont-
BooniMj:
Carrolll
ij| Randol{^
Benton I
Greene]
Washing!^
Madison]
Lawrence]
i Stone) Aindepend^
Crawford]
Van_Burenj ^['ci^nel|
jirpoins^iiir^
Franklin]
Jackson]
Crittenden]
Conway
Sebastian]
Faulknerl
Woodruff]
- ^j^ra7r7e| i
lonokel
rn) .1^ L
if 1 [ ‘ " »
Pulaski]
Monroe]
Saline]
Garland]
Montgomery]
Grant]
Arkansas]
Jefferson]
Daiias[:;
Lincoln]
^rnpsle^
Nevada
Calhoun]
Ouachita]
Miiierl
■if Chicot]
p Colurnb^
I A Ff I :
Union]
I Lita.^*t7] j 1 3|:
AIDS CASES
REPORTED
□
0
□
1 to 3
n
4 to 49
■
50 to 662
I Of the 3,583 Arkansans reported to be HIV+, 2,01 1 have been diagnosed with AIDS. (5/12/96)1
AIDS In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501) 661-2387.
NOTE: County of residence may
change from date of HIV test to date
of AIDS diagnosis.
Arkansas Department of Health HIV/AIDS Surveillance Program
Volume 93, Number 2 - July 1996
97
Weulem Wildlife
As Kaiirniera uiovf d Wsc. pimieers L L C
found animals as fxotir as the land^j|^..
buffalo, prairie dogs, bean, beaverl/iighorrr
sheep, cougars. »'olves und raitlesrfclMa.
The eagle became a national svmboi. < ■ *, \ '
-■ N :
* I he eagle became a national svmboi. -a ■ *. \ f
SyyjJ'M^oa^ » 2!^
A^^JaaC^^3oJ:i-^ry^ ,
thank
m made it
ha'^e a
yi 1 had no
, I did not
suchaproi
,ededpro&
.ouldlilceto^
^11 Yourpf^^
S«.f.;:“
‘^"""%10‘«
^here else
'Thanks again
for more
information
on how
you can help,
call AHCAF at
(501) 221-3033
or (800) 950-8233
Arkansas Health Care
Access Foundation, he.
those physicians who volunteer ^
W through the Arkansas Health J
r ^ C.are Access Foundation, . j
Thank You! ^ '
I As you can see from a sampling of
I letters we have received, your
^ involvement in our program is A
appreciated and in many
^ cases life-saving, .
THANK YOU FOR MAKING THE DIFFERENCE!
New Members
FT. SMITH
Asi, Wael, Internal Medicine/Pulmonary. Medical
Education, American University of Beirut, Lebanon,
1986. Internship/Residency, Good Smaritan Hospital,
Baltimore, Maryland, 1991/1993. Board certified.
HELENA
Cruz, Eduardo Vargas, Physical Medicine & Re-
habilitation. Medical Education, University of East,
RMMMC, College of Medicine, Quezon City, Philip-
pines, 1974. Internship, Jersey City Medical Center,
New Jersey, 1977. Residency, Jamaica Hospital and
VA Medical Center, Brooklyn, New York, 1980.
JONESBORO
Labor, Phillips Kirk, Ophthalmology. Medical
Education, Louisiana State University Medical School,
Shreveport, 1991. Internship, Louisiana State Univer-
sity Medical Center, 1992. Residency, Eye Foundation
Hospital, University of Alabama, 1995. Board eligible.
LITTLE ROCK
Beau, Scott Lawrence, Cardiovascular Disease/Elec-
trophysiology. Medical Education, McGill University,
Montreal, Quebec, Canada, 1987. Internship/Resi-
dency, Boston University Hospital, Massachusetts,
1988/1990. Fellowship, Barnes Hospital, St. Louis, Mis-
souri, 1996. Board certified.
Cook, Timothy Richard, Pulmonary/Critical Care.
Medical Education, University of Tennessee, Memphis,
1989. Internship/Residency, University of Texas Health
Science Center, San Antonio, 1990/1992. Board certified.
Murillo-Lopez Fernando H., Ophthalmology.
Medical Education, Johns Hopkins University School
of Medicine, Baltimore, Maryland, 1990. Internship,
Washington Hospital Center, 1991. Residency, Johns
Hopkins Hospital/Wilmer Eye Institute, 1994. Board
pending.
MALVERN
Martin, Joan Barbara, Family Practice. Medical
Education, University of Texas Medical School, Hous-
ton, 1979. Internship, University of Colorado, 1980.
Residency, Ft. Collins, 1982. Board certified.
MOUNTAIN VIEW
Varela, Charles D., Orthopedic Surgery. Medical
Education, University of New Mexico School of Medi-
cine, Albuquerque, N.M., 1985. Internship, Michigan
State University, Kalamazoo Center for Medical Stud-
ies, 1986. Residency, University of Missouri, Kansas
City, 1990. Board certified.
PINE BLUFF
Mohyuddin, Adil Ibrahim, Oncology/Hematol-
ogy. Medical Education, University of Tennessee,
Memphis, 1987. Internship/Residency, University of
Tennessee, Memphis, 1988/1990. Board certified.
VAN BUREN
Katz, Catherine A., General Practice. Medical
Education, Dalhousie University, Halifax, Nova Scotia,
Canada, 1968. Internship, Victoria General Hospital,
Halifax, Nova Scotia, Canada, 1968.
OUT OF STATE
Blackburn, Roy M., Physical Medicine & Reha-
bilitation. Medical Education, American University of
the Caribbean, Montserrat, British West Indies, 1987.
Internship, St. Vincent's Medical Center, Staten Island,
N.Y., 1988. Residency, St. Vincent's Medical Center
and Emory University, Atlanta, Ga., 1993. Board certified.
Gregory, John Reeves, Orthopedics. Medical Edu-
cation, Louisiana State University Medical Center,
Shreveport, 1982. Internship/Residency, Louisiana
State University Medical Center, Shreveport, 1978/1982.
Board certified.
Melton, Charles Lewis, Cardiology. Medical Edu-
cation, University of Texas Southwestern Medical
School, 1980. Internship, King/Drew Medical Center,
Los Angeles, Calif., 1981. Residency, King/Drew and
St. Vincent's Medical Center, 1987.
Wren, Mark A., Physical Medicine & Rehabilita-
tion. Medical Education, Tulane University School of
Medicine, 1991. Internship/Residency, Loma Linda
University Medical Center, Loma Linda, Calif., 1992/
1995. Board certified.
RESIDENTS
Albin, Amy Wilson, Pediatrics. Medical Educa-
tion, UAMS, 1996. Residency.
Baker, Karen R, Pediatrics. Medical Education,
UAMS, 1996.
Beeman, David Lyn, Family Practice. Medical
Education, UAMS, 1996.
Burton, Todd Michael, Pediatrics. Medical Educa-
tion, University of Texas Medical School, Houston, 1996.
Cameron, Ricky Leon, Family Practice. Medical
Education, University of Texas Medical Branch,
Galveston, 1996.
Volume 93, Number 2 - July 1996
99
Carr, Russell Shane, Family Practice. Medical
Education, Louisiana State University School of Medi-
cine, 1996.
Ceola, Ashley F., Radiology. Medical Education,
UAMS, 1996.
Corbell, Mark Edward, Family Practice. Medical
Education, UAMS, 1996.
Duffield, Robin Pilgram, Pediatrics. Medical Edu-
cation, UAMS, 1996.
Eads, Lou Ann, Psychiatry. Medical Education,
UAMS, 1996.
Fahr, Michael J. Medical Education, UAMS, 1996.
Frankowski, Gary A., Transitional. Medical Edu-
cation, UAMS, 1996.
Gregory, James Minor, Radiology. Medical Edu-
cation, UAMS, 1996.
Hodges, Michael Eugene, Family Practice. Medi-
cal Education, University of Texas Medical Branch,
Galveston, 1996.
Hogan, Scott Matthew, Psychiatry. Medical Edu-
cation, UAMS, 1995.
Iqbal, Imran, Internal Medicine. Medical Educa-
tion, Sindh Medical College, Karachi, Pakistan, 1990.
Jackson, Hugh H., Family Practice. Medical Edu-
cation, UAMS, 1996.
Jewell, Shannon A., Pediatrics. Medical Education,
UAMS, 1994.
Johnson, Brad D., Eamily Practice. Medical Edu-
cation, UAMS, 1996.
King, David L., Eamily Medicine. Medical Educa-
tion, University of Oklahoma College of Medicine,
Tulsa, 1996.
Marchese, Sandra Marie, Dermatology. Medical
Education, Northeastern Ohio University College of
Medicine, Rootstown, 1996.
McMahan, Steven Howard, Eamily Practice. Medi-
cal Education, UAMS, 1996.
Nguyen, Larry Luong, Orthopedic Surgery. Medi-
cal Education, Baylor College of Medicine, Houston, 1996.
Slack, Tobin Alexander, Eamily Practice. Medical
Education, Louisiana State University Medical Center, 1996.
Stewart, R. Todd, Internal Medicine. Medical Edu-
cation, UAMS, 1996.
Storey, Mark R., Radiation Oncology. Medical
Education, UAMS, 1996.
Vest, Carl Ernest, Eamily Practice. Medical Edu-
cation, UAMS, 1996.
STUDENTS
Dennis Neal Blake
LaRhonda Kay Sims
PHYSICIAN RESIDENT ALERT:
IF YOU COULD USE OVER $25/)00 A YEAR-
ANSWER THIS AD.
The U.S. Army’s Financial Assistance
Program (FAP) is offering a subsidy of over
$25,000 a year for training in certain medical
specialities.
Here’s how it breaks down - an annual
grant, plus a monthly stipend and reimburse-
ment of approved educational expenses.
You will be part of a unique health care
team where you will find many opportunities
to continue your medical education, work at
state-of-the-art facilities, and receive outstand-
ing benefits.
So, if you are a physician resident who
could use over $25,000 a year, contact an
Army Medical Counselor immediately.
800-USA-ARMY
ARMY MEDICINE. BE ALL YOU CAN BEf
100
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
Jon A. Roberts, M.D.
David R. McFarland, M.D.
Mohammed M. Moursi, M.D.
Don Thomas, M.D.
David Marshfield, M.D.
HISTORY
A 63-year-old white male presented with abnormal noninvasive study of a left femoral to anterior tibial venous
bypass graft. This was found on routine follow-up doppler examination. He was previously hypertensive and was
found to develop mild renal failure after being placed on an ACE inhibitor(Captopril).
Figure 1
Figure 2
Figure 1: An abdominal aortogram was obtained as part of the arteriogram to evaluate the left femoral to distal
bypass graft. This demonstrated a significant stenosis of the right renal ostium as was suggested by his clinical
response to ACE inhibition. There is mild irregularity of the left renal artery without significant stenosis. There is mild
irregular plaque in the infrarenal aorta.
Figure 2: Angiogram performed after balloon dilatation and stent placements.
Volume 93, Number 2 - July 1996
101
Renal Artery Stenosis Secondary to Atherosclerotic Disease
DIAGNOSIS
Renal artery stenosis secondary to atherosclerotic disease.
TREATMENT
Correction of this stenosis was undertaken due to the patient’s response to Captopril and hypertension. Utilizing
a left axillary access, the right renal artery was catheterized with the stenosis crossed. The lesion was initially dilated
with a 6mmx2cm angioplasty balloon. There was a moderate residual stenosis. Subsequently, a 6mm Palmaz renal
artery endovascular stent was placed with no residual narrowing on the follow-up arteriogram.
DICUSSION
Renal artery occlusive disease is a commonly encountered problem. Hypertension can be caused by renal artery
stenosis or worsened by it. Numerous studies have shown the adverse effects of occlusive disease on renal func-
tion.With these in mind, intervention of renal stenoses is now more prevalent. Current options include surgical
endarterectomy or bypass and percutaneous procedures such as were performed in this case.
There have been several reports documenting the efficacy of the Palmaz renal artery stent. One of the biggest
advantages it provides is the decreased elastic recoil which formerly was a problem in ostial lesions.® Initial technical
success is high and the restenosis is less than angioplasty alone. Restenosis occurs in some patients and is likely
secondary to myointimal hyperplasia. Redilatation can be performed if needed and is usually successful.
Reports have shown various responses in blood pressure and renal function.® ® Very few patients will be cured of
hypertension but many have the number and/or dose of their medications decreased. The effects on renal function
are more variable with some showing improvement, some not changing, and some even deteriorating. Some pos-
sible causes of worsened renal function include contrast nephropathy and cholesterol embolization induced by the
procedure.
The usual approach for placement of a renal stent would be from the common femoral artery. In this patient, the
axillary artery was utilized because of the threatened graft in the left groin and occlusion of the common femoral
artery. The axillary artery is not as desirable for intervention because of the larger sheaths required. However, in this
instance it was performed without complication and prevented the patient from having an abdominal surgery. Addi-
tionally, stent placement does not preclude future surgical bypass if needed.
In conclusion, percutaneous intervention with the Palmaz renal stent may be useful in patients with hypertension
or renal failure and co-existent renal artery stenosis.
REFERENCES
1. Rimmer,J.M.,Gennari F.J. Atherosclerotic renovascular disease and progressive renal failure. Annals of Internal Medicine
1993:118:712-719
2. Donovan R.M., Gutierrez O.H., Izzo J.L. Preservation of renal function by percutaneous renal angioplasty in high risk elderly
patients; shortterm outcome. Nephron 1992; 187-192.
S.Joffe F., Rousseau H., Bernadet P., et al. Midterm results of renal artery stenting. Cardiovascular and Interventional Radiology
1992;15:313-318.
4. van de Ven P.J.G.,Beutker J.J., Kaatee R.,et al. Transluminal vascular stent for ostial atherosclerotic renal artery stenosis.
Lancet 1995;346:672-74.
5. Rees C.R., Palmaz J.C., Becker G.J.,et al. Palmaz stent in atherosclerotic stenoses involving the ostia of the renal arteries:
preliminary report of a multicenter study. Radiology 1991;181:507-14.
Authors: Jon A. Roberts, M.D., is a vascular and interventional radiology fellow at UAMS. He will be joining Memphis Radiologi-
cal, PC this month; David R. McFarland, M.D., is chief of interventional radiology at UAMS; Mohammed M. Moursi, M.D., is
assistant professor in vascular surgery at UAMS and Don Thomas, M.D., is a senior resident in radiology at UAMS.
Editor: David Marshfield, M.D., is Director of Radiology at Riverside Imaging Center and Clinical Associate Professor of Radiol-
ogy at UAMS.
102
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Take the mobile phone off the hook.
Riverside Motors, Inc.
1403 Rebsamen Park Rd./Little Rock, AR 72202
666-9457 & 1-800-457-6226
*MSRP for an E300 Diesel Sedan excludes $595 transportation charge, all taxes, title/documentary fees, registration, tags, dealer prep
charges, insurance, optional equipment, certificate of compliance or noncompliance fees, and finance charges. Prices may vary by dealer.
E320 Sedan shown at MSRP of $43,500. ©1995 Authorized Mercedes-Benz Dealers
We can't guarantee that they'll follow in your footsteps, but we do know they need good health insurance
today. And so do you.
FINALLY, a health insurance plan designed to meet the needs of Arkansas' physicians. The ARKANSAS
MEDICAL SOCIETY HEALTH BENEFIT PROGRAM... offering a variety of benefit options including a choice
between basic indemnity and managed care. For information call (501) 224-8967 or 1-800-542-1058.
Arkansas Medical Society
Health Benefit Program
Underwritten by
American Investors
Life Insurance Company
In cooperation with
Arkansas Managed
Care Organization
Exclusively for members of the Arkansas Medical Society. Developed by AMS BENEFITS, INC. in conjunction with American
Investors Life and Arkansas Managed Care Organization.
AMS BENEFITS, INC
A wholly owned subsidiary of the Arkansas Medical Society
P.O. Box 55088, Little Rock, Arkansas 72215-5088 • (501)224-8967 * WATS 1-800-542-1058 * FAX (501) 224-6489
In Memoriam
John E Guenthner M,D,
Dr. John F. Guenthner, of Mountain Home, died Tuesday, May 21, 1996.
He was 91. Survivors include his wife, Aileen: a son, Charles; one grandson;
one great-grandson; four stepsons; 13 step-grandchildren; and five step-great-
grandchildren.
Things To Come
July 31 - August 3
Arkansas Academy of Family Physicians - 49th
Annual Scientific Assembly. Little Rock Excelsior
Hotel & Statehouse Convention Center. For more in-
formation, call (501) 223-2272 or in-state 1-800-592-1093.
August 26 - 29
Current Concepts in Primary Care Cardiology.
Hyatt Regency Lake Tahoe, Incline Village, Nevada.
Sponsored by UC Davis School of Medicine and Medi-
cal Center Division of Cardiovascular Medicine, De-
partment of Internal Medicine and the Office of Con-
tinuing Medical Education. For more information, call
(916) 734-5390.
September 6-7
3rd Annual Current Topics in Cardiothoracic
Anesthesia. Washington University Medical Center,
St. Louis, Missouri. Sponsored by the Office of Con-
tinuing Medical Education, Washington Univ. School
of Medicine. For more information, call 1-800-325-9862.
October 5-6
Lymphomas and Leukemia; Clinical Advances,
Basic Science and Supportive Care Issues. J. Bennett
Johnston Building, Tulane University Medical Center,
New Orleans, LA. Sponsored by Tulane University
Medical Center, Tulane Cancer Center, Center for Con-
tinuing Education and Nursing Resource Center. For
more information, call (504) 588-5466 or 1-800-588-5300.
October 9-13
Infectious Disease '96 Board Review Course - A
Comprehensive Review for Board Preparation. The
Hyatt Regency Hotel, Washington, D.C. Sponsored
by the Center for Bio-Medical Communication. For
more information, call (201) 385-8080.
October 17 - 19
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
November 1-3
New Developments in the Pathogenesis & Treat-
ment of NIDDM (non-insulin dependent diabetes
mellitus). Radisson Resort, Scottsdale, Arizona. Spon-
sored by the American Diabetes Association of Ari-
zona and the National Institute of Diabetes and Di-
gestive and Kidney Diseases. For more information,
call (602) 995-1515.
November 14 - 17
15th Annual Scientific Meeting - Pain and Dis-
ease: Causes, Consequences, and Solutions. Sheraton
Washington Hotel, Washington, DC. Sponsored by the
the American Pain Society. For more information, call
(847) 375-4715.
November 20 - 24
90th Annual Scientific Assembly - Yesterday's
Caring with Today's Technology. Baltimore Conven-
tion Center, Baltimore, Maryland. Sponsored by the
Southern Medical Association. For more information,
call (800) 423-4992 or (205) 945-1840.
December 7
Cardiology Seminar. Washington University Medi-
cal Center, St. Louis, Missouri. Sponsored by the Of-
fice of Continuing Medical Education, Washington Uni-
versity School of Medicine. For more information, call
1-800-325-9862.
Volume 93, Number 2 - July 1996
105
Career Solutions. STAT.
CZ^oastal Physician
Services of the Midwest,
Inc. currently has pri-
mary and supplemental
opportunities for
Emergency Department
physicians at many
Arkansas locations.
Choose Jonesboro, Searcy, Heber
Springs or Walnut Ridge. Competitive
remuneration. Malpractice insurance
can be procured on physician’s behalf.
rOASTAT
PHYSICIAN SERVICES
OF THE MIDWEST, INC.
Contact Brooks K. Crump II aM- 800-777-1 301 to learn
more about specific opportunities at these locations.
MEDICAL EQUIPMENT
FOR SALE
X-ray Machine Konica Film Processor
Exam Table Kodak Analyzer DT60
EKG Machine Microscope
Flexible Sigmoidoscope
Contact: D.A. Poindexter, M.D.
810 Parkway
Conway, AR 72032
(501)327-0262
Emergency Medicine Opportunities
C/J
Full and Part-Time Opportunities in:
• Mena • Helena
C/J
• Van Buren • West Memphis
WE OFFER: Competitive Remuneration,
<
Occurrence Maipractice & Flexible Hours
For more information on these and other
opportunities in Arkansas please contact:
C
Tom Kubiak 800-325-2716 or
FAX CV to Tom at 314^919-8920.
PHYSICIAN
Part Time
Men’s Health Center of Little Rock
now hiring a Licensed Physician for
evaluation, treatment and follow-up of
small patient load. No weekends, holi-
days or call. Competitive Compensation
and Flexible Schedule. Send Resume/
C.V. to:
50 Midtown Park West
Mobile, AL 36606
or call:
334-471-9991
Attention Sam Kelley
ARKANSAS - BC/BE family physicians
needed for expanding primary care network.
No financial risk. Exceptional salary, sign-
ing bonus, loan repayment assistance. Call
1 :4, university, great schools, affordable hous-
ing, 1 hour to major metro. Call or send C.V.
with cover to Jane Vogt, 1-800-546-0954,
I.D. #3979JA, 222 S. Central, Suite 700, St.
Louis, MO 63105, FAX: 314-726-3009,
E-mail: careers@cejka.com.
ARKANSAS ACADEMY OF FAMILY PHYSICIANS
49 »' ANNUAL SCIENTIFIC ASSEMBLY
JULY 31 - AUGUST 3, 1996
LITTLE ROCK EXCELSIOR HOTEL
& STATEHOUSE CONVENTION CENTER
UP TO 24 '/2 HOURS OF
CONTINUING MEDICAL EDUCATION AVAILABLE
FOR MORE INFORMATION,
CONTACT THE AAFP OFFICE
(501)223-2272 OR IN-STATE TOLL FREE 1-800-592-1093
106
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Keeping Up
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category I of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Spine Center Conference, 1st Wednesday, 7:00 a.m., Southwestern Bell/Arkla Room. Light Breakfast provided.
Urology Grand Rounds, September 17th and November 5th, 5:30 p.m.. Southwestern Bell/Arkla Room, Refreshments provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
As an organization accredited for continuing medical education by the Accreditation Council for Continuing Medical Education, the
University of Arkansas for Medical Sciences certifies the following continuing medical education activities meet the criteria for Category I
of the Physician's Recognition Award of the American Medical Association.
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Oncology Forum, Thursdays, 4:00 p.m., UAMS ACRC 2nd Floor Board room, 1.5 credits
Anesthesia Lecture Series, Wednesdays, 4:00 p.m., UAMS Education Bldg., room G/110 A&B
Anesthesia Morbidity & Mortality Conference, Tuesdays, 6:45 a.m.; 2nd & 4th Thursdays, 4:00 p.m., UAMS Education Bldg.,
room G/110 A&B
Volume 93, Number 2 - July 1996
107
Cardiology Graphics Conference, Tuesdays, 12:00 noon, VAMC, room 5C114
CARTI North Tumor Board Cancer Conference, 2nd Wednesday, 12:00 noon, CARTI North, Searcy
Cardiothoracic Surgery Conference, date, time, & location varies
Cardiothoracic Surgery Monthly Journals Club, 4th Saturday, 9:30 a.m., UAMS Surgery Dept. Library, room 2S/28D
Cardiothoracic Surgery Morbidity & Mortality Conference, 2nd Saturday, 9:30 a.m., UAMS Surgery Dept. Library, room 2S/28D
Child Psychiatry Update/Case Conference, 3 Fridays per month, 1:00 p.m., ACH Child Study Center conference room
CME Outreach Program, dates, times & locations vary
EKG Conference, Mondays, noon, VAMC, room 5C114
Emergency Medicine Didactic Conference 1, Thursdays, 7:00 a.m. UAMS Education Bldg., room G/llOA&B
Emergency Medicine Didactic Conference 2, Thursdays, 8:00 a.m., UAMS Education Bldg., room G/llOA&B
Emergency Medicine Didactic Conference 3, Thursdays, 9:00 a.m., UAMS Education Bldg., room G/llOA&B
Emergency Medicine Grand Rounds 1, Tuesdays, 7:00 a.m., UAMS Education Bldg., room G/llOA&B
Emergency Medicine Grand Rounds 2, Tuesdays, 8:00 a.m., UAMS Education Bldg., room G/llOA&B
Endocrinology Case Conference, Fridays, 7:30 a.m., ACRC 3rd floor conference room
Family Practice Grand Rounds, Tuesdays, 12:15 p.m.. Family Practice Center, 6th and Elm
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m.. Gastroenterology conference room, 3D29
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Radiology conference room, Ml/293
Hematology/Oncology Fellow's Forum, Fridays, 8:15 a.m., ACRC Betsy Blass conference room
Joint Cardiology-Cardiovascular Thoracic Surgery, Wednesdays, noon, UAMS, room S306
LR Cancer Conference, Wednesdays, 12:00 noon, UAMS ACRC conference room 3 times a month, CARTI Auditorium once a month
LR Vascular Conference, time & date varies monthly, rotates between UAMS, SVI & BMC
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education Bldg., room G/131A&B
Med/Path Conference, 3rd or 4th Tuesday, 3:00 p.m., UAMS Shorey Bldg., room S/306
Medicine Journal Club, alternate Thursdays, 7:30 a.m., ACC Medicine Clinic conference room
Medicine Research Conference, Wednesdays (except 3rd), 4:30 p.m. UAMS Education Bldg, room B/135
Neurology-Neuropathology Conference, Wednesday's, 4:00 p.m.. Room 2E-142 at VAMC
Neurology-Neuradiology Conference, Wednesday's, 5:00 p.m.. Room 2E-142 at VAMC
Neuroscience Clinical Grand Rounds, Monday's, 3:00 p.m., Betsy Blass Conference Room, Arkansas Cancer Research Center
Neuroscience Conference (Basic), Mondays, 8:00 a.m., UAMS 7D33
Neuroscience Conference (Basic & Clinical), Wednesdays, 4:00 p.m., UAMS 7C
Neurosurgery Journal Club, 2nd & 4th Thursdays, 8:00 p.m., 2 credit hours
Neurosurgical Pathology Conference, Thursdays, 4:00 p.m., VAMC-LR Neuropathology conference room, 2E141
OB/GYN Fetal Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education Bldg., room G/131B
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Ophthalmology Residency Morning Lectures, Mondays, Wednesdays, Fridays, 7:30 a.m., UAMS Jones Eye Institute
Orthopaedic Basic Science Conference, Tuesdays, 8:00 a.m., UAMS Education Bldg., room B/135
Orthopaedic Bibliography Conference, Tuesdays, 8:30 a.m., UAMS Education Bldg., room B/135, 1.5 credit hours
Orthopaedic Fracture Conference, Tuesdays, 7:30 a.m., UAMS Education Bldg., room B/135
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education Bldg., room B/135
Pathology Autopsy Conference, Wednesdays, 12:00 noon, VAMC-LR Morgue
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Basic Sciences Conference, 1st Saturday, 7:30 a.m., ACRC 2nd floor conference room
Surgery Grand Rounds, Saturdays, 8:30 a.m., ACRC 2nd floor conference room
Surgery Morbidity & Mortality Conference, Saturdays, 9:30 a.m., ACRC 2nd floor conference room
Surgery Resident Case Conference, Saturdays (except 1st), 7:30 a.m., ACRC 2nd floor conference room
Trauma Morbidity &r Mortality Conference, date & time varies monthly, ACRC 2nd floor conference room
Urology Adult Subject Oriented Conference, once monthly, 5:00 p.m., VAMC-LR, 4D
Urology Basic Sciences Conference, 2nd Tuesdays, 5:00 p.m., VAMC-LR, 4D resident office
Urology Clinical Didactic Conference, 3rd Tuesday, 5:00 p.m., VAMC-LR, 4D
Urology Formal Teaching (Grand) Rounds, once or twice monthly, 5:00 p.m., VAMC-LR, 4D
Urology Journal Club, once a month, 5:00 p.m., VAMC-LR, 4D
Urology Morbidity & Mortality Conference, once monthly, 5:00 p.m., VAMC-LR, 4D
Urology Pathology Conference, 4th Thursday, 5:00 p.m., VAMC-LR, 4D
Urology Pediatric Conference, once monthly, 5:00 p.m., ACH Sturgis Bldg., Clinic 2
Urology Pre-op/Didactic Conference, Mondays, 5:00 p.m., VAMC-LR, 4D
Urology Radiology Conference, 1st Thursday, 5:00 p.m., UAMS, Radiology Department
Urology Teaching Conference, Wednesdays, 5:00 p.m., VAMC-LR, 4D
Urology VA Teaching Rounds, every Friday, 7:30 a.m., VAMC-LR, 4D
Uro-radiology Conference (Urologic Imaging), 1st Tuesdays, 5:00 p.m., UAMS Radiology conference room
VA Chest Conference (combined Surgical/ Medical Chest Conference), Mondays, 12:15 p.m., VAMC-LR, room 2D109
VA Diagnostic Imaging Conference, Monday-Thursday, 8:00 a.m., VAMC-LR Nuclear Medicine conference room, room 1D173
VA GREEd Geriatric Research Conference, Tuesdays, 4:00 p.m., VAMC-LR, room 2D109
108
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
VA Hematology /Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
AHEC Residency Program Noon Conferences, 12:30 p.m., Tuesday-Friday, AHEC Building
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Independence County Medical Society, 2nd Tuesday, 7:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroradiology Conference, 3rd Friday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Volume 93, Number 2 - July 1996
109
Geriatrics Conference, 3rd Friday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Conference, 2nd & 4th Wednesday, 12:00 noon, Jefferson Regional Medical Center
Obstetncsl Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Thursday, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Surgery Conference, 1st Friday, 12:00 noon, Jefferson Regional Medical Center
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Wednesday, 12:30 p.m., St. Michael Hospital
Neuro-Radiology Conference, 2nd & 4th Tuesday, 12:00 noon, Wadley Regional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
COULD YOU USE AN EXTRA $10,000!
The Army Reserve will pay you a yearly sti-
pend which could total in excess of $10,000 in the
Army Reserve’s Specialized Training Assistance
Program (STRAP) if you are a resident in:
general surgery, cardiothoracic surgery, periph-
eral vascular surgery, colon-rectal surgery,
orthopedic surgery, neurosurgery, urology,
anesthesiology, diagnostic radiology, family
practice, emergency medicine or internal
medicine.
Once you complete your residency you
will have opportunities to continue your edu-
cation and attend conferences. Your commit-
ment in the Army Reserve is generally one
weekend a month and two weeks a year or 12
days annually. You can also choose a non-
active assignment and receive one-half of the
authorized stipend.
Get a maximum amount of money for a
minimum amount of service. Find out more by
contacting an Army Reserve Medical Counselor.
Call:
800-USA-ARMY
ARMY RESERVE MEDKINE. BE ALL YOU CAN BE!
110
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Volume 93, Number 2 - July 1996
111
Advertisers Index
Advertising Agencies in italics
AMS Benefits 104
Arkansas Blue Cross & Blue Shield Ill
Arkansas Children's Hospital 73
Arkansas Managed Care Organization 70
Autoflex Leasing inside front
Freemyer Collection System Ill
The Paul Revere Life Insurance Company 87
Riverside Motors, Inc 103
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory back cover
Strategic Marketing
State Volunteer Mutual Insurance Company 66
The Maryland Group
UAMS-AHEC Program &
Tulane Medical Center inside back
U.S. Air Force 74
BJK&E Specialized Advertising
U.S. Air Force Reserve 65
HMS Partners, Inc.
U.S. Army Active 100
Young & Rubicam, Inc.
U.S. Army Reserve 1 10
Young & Rubicam, Inc.
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
journal. Material appearing in The Journal of the Arkansas
Medical Society is protected by copyright. Manuscripts
may not be reproduced without the written permission of
both author and The Journal of the Arkansas Medical Society.
The Journal of the Arkansas Medical Society reserves the
right to edit any material submitted. The publishers accept
no responsibility for opinions expressed by the contribu-
tors.
All manuscripts should be submitted to Tina G. Wade,
Managing Editor, Arkansas Medical Society, P.O. Box
55088, Little Rock, Arkansas 72215-5088. A transmittal
letter should accompany the article and should identify
one author as the correspondent and include his/her
address and telephone number.
MANUSCRIPT STYLE
Author information should include titles, degrees,
and any hospital or university appointments of the
author(s). All scientific manuscripts must include an
abstract of not more than 100 words. The abstract is a
factual summary of the work and precedes the article.
Manuscripts should be typewritten, double-spaced, and
have generous margins. Subheads are strongly encour-
aged. The original and one copy should be submitted.
Pages should be numbered. Manuscripts are not re-
turned; however, original photographs or drawings will
be returned upon request after publication. Manuscripts
should be no longer than ten typewritten pages. Excep-
tions will be made only under most unusual circum-
stances.
Along with the typed manuscript, we encourage you
to submit an IBM-compatible 5 1/4" or 3 1/2" diskette
containing the manuscript in ASCII format. The manu-
script on diskette must be in the same format as stated
above. We will return the diskette upon request.
REFERENCES
References should be limited to ten; if more than ten
are listed, the author(s) may designate the ten most
significant to be printed and readers will be referred to the
authors(s) for the complete list. References must contain,
in the order given: name of author(s), title of article, name
of periodicals with volume, page, month and year. Refer-
ences should be numbered consecutively in the order in
which they appear in the text. Authors are responsible for
reference accuracy.
ILLUSTRATIONS
Illustrations should be professionally drawn and/or
photographed. Glossy black and white photos are pre-
ferred. They should not be mounted and should have the
name of the author(s) and figure number penciled lightly
on the back. An arrow should indicate the top of the
illustration. In photographs in which there is any possi-
bility of personal identification, an acceptable legal release
must accompany the material. Up to four illustrations will
be accepted at no charge to the au thor(s). If more than four
are necessary, it is understood that the author(s) will be
responsible for the reproduction costs.
REPRINTS
Reprints may be obtained from The Journal office and
should be ordered prior to publication. Reprints will be
mailed approximately three weeks from publication date.
For a reprint price list, contact Tina G. Wade, Managing
Editor, at The Journal office. Orders cannot be accepted for
less than 100 copies.
THE Journal
OF THE Arkansas
HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND, AT
BALTIMORE
August 1996
93 Numbsr 3
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page 125
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE PRESIDENT
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
ObstetricsIGyvecology
htterml Medicine
Surgery
Family Practice
UAMS
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information: Contact Tina G. Wade, The
Journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster: Send address changes to; The journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
Press, Inc., Fulton, Missouri 65251. Periodicals postage
is paid at Little Rock, Arkansas, and at additional
mailing offices.
Articles and advertisements published in The Journal
are for the interest of its readers and do not represent
the official position or endorsement of The Journal or the
Arkansas Medical Society. The Journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1996 by the Arkansas Medical Society.
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
Volume 93 Number 3 August 1996
CONTENTS
FEATURES
116 Let's Build a Medical Care Delivery System Like
We Built the Atomic Bomb - Editorial
Alex E. Finkbeiner, M.D.
120 Medicine in the News
Health Care Access Foundation Update
COBRA Cases and Definitions
Snell Lab Provides Coupons for Donation to Arkansas Chapter of ADA
Dietary Supplement Can Be Fatal
Race for the Cure
Disciplinary Action Bulletin - Arkansas State Board of Nursing
123 New Member Profile
George Givens Miller, M.D.
125 Backflow Prevention Devices Required for Medical
Facilities on many Public Water Systems - Special Article
Thomas L. Fans, M.D.
129 Basic Rules for Being a Witness - Legally Speaking J T
David L. Ivers, J.D. ^ • | Cover Story
131 Dramatic Changes are Taking Place in the Twin Cities
Tyler Hardeman
133 The State's Newest Family Practice Residency Program
Comes of Age - Special Article
George M. Finley, M.D.
Rebecca Hyatt, B.S., C.P.M.
137 Invasive Non-typeable Haemophilus Influenzae Disease in
Children - Scientific Article
Gordon E. Schutze, M.D.
Stephen F. Garrison, M.D.
155 In Fond Memory of AMS Immediate Past President
James Armstrong, M.D.
DEPARTMENTS
122 AMS Newsmakers
118 Mail
139 Cardiology Commentary & Update
143 State Health Watch
146 Arkansas HIV/AIDS Report
149 New Members
151 Radiological Case of the Month
153 In Memoriam
156 Things to Come
157 Keeping Up
Cover photograph taken by A.C. Haralson of the Arkansas Department of Parks & Tourism.
Editorial
Let's Build a Medical Care Delivery System
Like We Built the Atomic Bomb
Alex Finkbeiner, M.DA
Our federal and state governments have adopted
a predictable approach to problem solving; particularly
regarding social issues. An issue is identified (many
times motivated solely for political gain but that's an-
other essay); consultants are brought to committee
meetings where data is presented and opinions ex-
pressed; debates ensue; compromises are made; a vote
is taken and, if passed, monies are appropriated and
the program (solution) is enacted and unleashed upon
the American public as a mandate. Rarely is a
well-defined outcome identified or means established
to evaluate the effectiveness of the program. The pro-
grams are rarely field-tested and once instituted seem-
ingly continue forever.
Pick up any Sociology textbook and you will find
the first chapter devoted to defending Sociology as a
science adaptable to scientific methods. I propose that
sociological issues (medical care delivery is one) can,
indeed, be addressed scientifically but are seldom done
so by our governments.
During the flurry of activity of the first 100 days of
Clinton's first term, Hillary Clinton was quoted (I para-
phrase) "We are facing a medical crisis that will re-
quire the equivalent of the Manhattan Project to solve".
Ignoring the word crisis as mere political hyperbole
my reaction to her statement was the Clintons had
learned something from history and would address
social problems in a rational, scientific way. Of course,
they didn't apply the principles of the Manhattan
Project addressing medical care and the issue never
came to fruition.
The Manhattan Project was the code name for the
project to develop the atomic bomb in the early 1940's.
I would argue that it is a paradigm of how govern-
ments should address problems; including social prob-
lems. The moral and ethical aspects of nuclear warfare
is not an issue here. The issue is the methodology by
* Dr. Finkbeiner is Professor of Urology in the Dept, of Urology
at UAMS. He is a member of the editorial board for The Joiirjial
of the Arkansas Medical Society.
116
which problems are solved. Once a decision was made
to develop the bomb, the government did it the right way.
First, the bomb was to be designed for a specific
purpose; a specific outcome was defined. Next, two
primary groups of individuals, the theoretical and the
experimental physicists, were brought together iso-
lated from congressional hearings and compromise to
solve the problem. The theorists' role was to present
historic data and theories extant regarding atomic
physics in a reasoned and logical manner and submit
theoretical approaches to solving the problem. The
experimentalists then tested these theories, accepting
those that were provable and applicable and rejecting
those that were not. After many interactions of these
two groups a functional bomb to meet the previously
defined objective was designed. Before putting the
device into service it was tested in a remote desert
and only after successful testing was the bomb actu-
ally employed and only for a finite purpose (ending
the war). When the original objective was met the
project was disbanded.
If governments are intent to "solve the health care
crisis" let us return to Hillary's suggestion and utilize
the Manhattan Project paradigm.
First, define the problem and establish desirable,
measurable outcomes or objectives.
Next, invite the theoreticians (eggheaded academic
consultants and anyone else who has a theory) to out-
line alternative health care delivery systems to meet
the previously defined objectives.
Pick five different systems, divide the United States
into five regions, assign one system to each region
and then experiment. By federal mandate all individu-
als within a region will receive their health care solely
under the system assigned to that region for a finite
time; lets say five years. In other words, each of the
five regions will operate under one of the five health
care delivery systems for five years.
The measurable outcomes are then evaluated at
the end of five years to evaluate each program.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
By field testing (experimentation) alternative pro-
grams (theoretical) and evaluating possible solutions
based upon clearly defined and measurable outcomes
we could then confidentially choose one program of
health care delivery to be instituted nationwide with
predictable results and a reasonable expectation of
success. Further, outcomes would be continually moni-
tored and, if the program fails to meet our objectives
or if objectives change we would be willing and able
to abandon that system and evaluate others.
Is it too farfetched to ask our governments to con-
sider more rational approaches to problem solving
through experimentation and outcome monitoring
combined with the resolve to reject or discontinue pro-
grams that do not meet expectations? For medical is-
sues the same scientific approaches utilized to under-
stand the pathophysiology and treatment of diseases
should be applied to the issue of how health care is
delivered.
Advanced CPT &
ICD-9-CM Coding:
Beyond The Basics
Sponsored by the Arkansas Medical Society
October 30 and 31, 1996
Riverfront Hilton - NLR
Who will benefit from this seminar?
The ADVANCED CODING PROGRAMS are
advanced level classes for physicians and coding/
billing staff.
Program Outline
The Advanced Coding programs emphasize optimal
reimbursement coding, related documentation
issues, undercoding and unbundling, reviewing and
appealing underpaid and denied claims, and
optimal “linking” of CPT to ICD-9-CM codes.
Advanced CPT Coding Covers:
* Evaluation/Management Codes* Medicine and
Surgery Codes*Radiology, Lab & Path
Codes*Modifiers*Unlisted Procedure
Codes*HCPCS Level II Codes
Advanced ICD-9-CM Coding Covers:
*Coding Rules & Format of ICD-9-CM* Alphabetic
& Tab Listings*General & HCFA
Guidelines*Medical & Surgical Diagnoses (Circu-
latory Disorders, Neoplasms, OB/GYN, Injuries,
Late Effects, Complications, Poisoning &Adverse
Effects, Mental Disorders, V Codes & E Codes
For more information, call the AMS office
at 1-800-542-1058 or in Little Rock 224-8967
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Send your letters to the editor for publication in the Mail section to: Tina G. Wade, Arkansas Medical Society, P.O. Box
55088, Little Rock, AR 72215-5088.
Points Clarified Related to Article
on Mercury in Fish
On behalf of the Arkansas Mercury Task Force, I
would like to thank you for publishing the article con-
cerning the problem of mercury in fish. As stated in
the article, this is a problem with which we can learn
to live. (The article, titled Arkansans learning to live with
mercury in fish, was in the "Outdoor MD" section of
Volume 92, Number 10, March 1996 issue of The Journal.)
The communication of technical issues is extremely
difficult, often rendering it almost impossible to tell
the whole story in a limited article. There are a couple
of points related to this article which I feel need to be
clarified.
1. The article states that only largemouth bass and
catfish are affected. Actually, flathead catfish have been
observed to have considerably higher concentration
of mercury than other species of catfish. Most other
species of catfish have low concentrations of mercury
although the rule that larger fish have more mercury
still holds.
2. Reference is also made to possible sources of
the mercury problem. Most states have focused in on
the possibility that mercury originates from the atmo-
sphere which would mean that the likely source would
be the burning of coal or wastes. Some states have
gone as far as recommending that mercury emissions
from such sources be controlled which would be very
costly. Observations of the distribution of mercury in
sediments, rocks, and soils in Arkansas suggest the
possibility that the source may be completely natural.
For example, the analysis of over 700 rock samples
from the Ouachita Mountains show that the average
concentration of mercury is very near that of the sedi-
ment found in the Ouachita River. At this point, there
is no firm answer as to the source but we are suggest-
ing that it is important that we further evaluate the
possibility that the source is natural before we spend
massive amounts of money cleaning up atmospheric
mercury emissions. Hopefully this can be done in the
near future.
3. Some people continue to ask why the problem
seems to appear in only certain locations. To explain
this, one must understand that there are three things
required to have a mercury problem. First, there must
be a source; second, conditions necessary to produce
methyl mercury must be present which usually means
anaerobic sediments, third, a food chain which includes
a predator fish (feeds on other fish) must be present.
Remove any one of these factors and there is no prob-
lem. For example, even if mercury is present in river
sediment, if the sediment is well oxygenated, there is
not a problem.
I do not know if it is your policy to publish letters
intended to expand on articles but I do think it would
be appropriate for your readers to understand these issues.
Joe F. Nix, Ph.D.
Chairman, Arkansas Mercury Task Force
The Susan G. Komen
Breast Cancer Foundation
RACE FOR THE CURE
Presented by JCPenney
September 21, 1996 in Little Rock
For more information,
see page 121 and contact
the Race Headquarters at
Barbara Graves Intimate Fashions
(501) 227-5561
CORRECTION NOTICE:
The following group of physicians was listed in
the previous (July) issue of The Journal in the "AMS
Newsmakers" section without the proper information.
Christopher Adams, Little Rock; Lester T.
Alexander, Pine Bluff; Ron William Beckel, Little
Rock; Elizabeth Ross Chambers, Harrison; Jay Dou-
glas Holland, Little Rock; Matthew Kyle McAlister,
Mountain Home; Robert Lyle Morris, Harrison;
Debra Jo Morrison, Little Rock; Mose Smith, Little
Rock; Aubrey Lawrence Travis, Van Buren.
They are the May 1996 recipients of the
Physician's Recognition Award which is awarded
each month to physicians who have completed ac-
ceptable programs of continuing education.
118
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Medicine in the News
Health Care Access Foundation
As of July 1, 1996, the Arkansas Health Care Ac-
cess Foundation has provided free medical service to
11,229 medically indigent persons, received 20,484 ap-
plications and enrolled 40,293 persons. This program
has 1,736 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
COBRA Cases and Definitions
During the June 21 Arkansas Hospital Association's
(AHA) Administrators Forum meeting, Diane Mackey,
AHA's attorney, gave a presentation related to a new
wave of COBl^ cases in Arkansas and across the na-
tion. According to Mackey, plaintiff lawyers are try-
ing to turn what should be malpractice cases into
COBRA claims which are less costly and easier to win.
Baptist Medical Center in Arkadelphia and Crittenden
Memorial Hospital in West Memphis are currently
embroiled in litigation concerning interpretation of
these laws. Some of the definitions used in her pre-
sentation are listed below:
*Any individual who comes to the emergency
department is defined broadly. There is no need for a
patient to show indigency, eligibility for Medicare, or
any bad motive by the hospital for the patient to be
protected by the Act.
’^Qualified medical personnel include those which
the hospital defines by bylaws or rules and regula-
tions. Because of assessment responsibility, the Health
Department says a qualified medical person must at
least be a Registered Nurse.
^Capacity means the ability of a hospital to ac-
commodate individuals and includes numbers, avail-
ability of qualified staff, beds and equipment, as well
as the hospital's past practice of accommodating ex-
cess capacity.
^Emergency medical condition manifests itself by
acute symptoms of sufficient severity, including pain,
psychiatric disturbances or indications of substance
abuse which will, without medical attention, reason-
ably be expected to place the health of the individual
(including an unborn child) in serious jeopardy, or
serious dysfunction of any bodily organ or part, or if
there is not time to transfer safely in the case of a
woman having contractions or the transfer itself poses
a threat to the health and safety of either mother or child.
^Hospital includes a rural primary care hospital.
Participating hospital is one with a Medicare provider
agreement.
^Stabilized means, if there is an emergency medi-
cal condition, that no material deterioration is likely,
within reasonable medical probability, to result from
or occur during a transfer or delivery.
120
^Transfer means movement (including discharge)
of an individual outside the hospital's facility at the
direction of a hospital agent, unless the individual is
dead or leaves without permission.
^Appropriate medical screening examination
within the capability of the hospital, including an-
cillary review routinely available at the emergency
department means that screening which is usual and
uniformly available to everyone presenting in similar
condition at the ER. This has slightly different mean-
ings in different jurisdictions.
Mackey suggested that should a hospital have no
time to call an attorney, officials should check these
definitions which will probably provide an answer, if
read closely. Look at what is included, what is not
included, and what duty must be met.
Reprinted from The AHA Weekly NOTEBOOK, Vol.
3, No. 26, an Arkansas Hospital Association newsletter,
dated July 9, 1996.
Snell Lab Provides Coupons for Donation
to Arkansas Chapter of ADA
Snell Laboratory and the American Diabetes As-
sociation (ADA) have teamed up to offer a special pro-
gram to benefit the ADA and the diabetic population
of Arkansas. The program will introduce coupons de-
signed and printed by Snell for consumers of diabetic
shoes. For each coupon redeemed (or each offer men-
tioned) at the time of any diabetic shoe purchase, Snell
Laboratory will donate $5 to the Arkansas chapter of
the ADA in support of its programs.
Physicians may obtain coupons for their patients
at any Snell Laboratory office or the American Diabe-
tes Association. The coupons will also be available
through Baptist Hospitals, St. Vincent's Infirmary and
the Med Center in Little Rock, as well as other hospi-
tals and diabetes education programs throughout the
state. In addition, coupons will be distributed by the
ADA at various in-service events for diabetics across
the state.
As diabetics often lose feeling and sensation in
their extremities, the feet are especially vulnerable and
pose a continuing problem; a significant portion of
cases at the Little Rock Foot Clinic are diabetic, said
Terri Cohen, D.P.M. Cohen reports a case where a
patient walked for a full day with a tack in his shoe
before discovering it - and had done considerable dam-
age to the sole of his foot.
"You can't be too careful with your feet when dia-
betes is in the picture. Twenty percent of diabetic hospi-
tal admissions are for foot problems and their treatment."
Dietary Supplement Can Be Fatal
The Food and Drug Administration (FDA) recently
warned that the stimulant, ephedrine, which the FDA
classifies as a dietary stimulant, can cause heart at-
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
tacks, seizures and psychosis. The warning followed
the death of a college student who took an herbal prod-
uct called ULTIMATE Xphoria, which contains ephe-
drine. The herbal product was described by the FDA
as an imitation of the illegal drug called Ecstasy.
Reprinted from the Information for the Medical Com-
munity and the Public from the D.C. Board of Medicine
newsletter dated May 1996.
Race for the Cure
On Saturday, September 21, 1996, Arkansas will
hold its third annual Susan G. Komen Breast Cancer
Foundation Race for the Cure, presented by JCPenney.
Dr. Sandra B. Nichols, Director of the Arkansas De-
partment of Health, has been chosen to serve as hon-
orary chair of this year's Race.
"The Department of Health is proud to be a part
of the 1996 Race for the Cure. While more white women
in Arkansas are diagnosed with breast cancer each year,
minorities are dying from it at a faster rate. To increase
awareness of this problem, I would like to encourage
community-wide involvement, including physicians
and more minority participation, in the Race," says
Dr. Nichols.
The Department of Health's Arkansas Breast and
Cervical Cancer Control Program offers free
mammograms, pap tests, and clinical breast exams
to women who cannot afford them and are eligible
for the program.
The race includes a 5K women's Walk/Run and a
2K family Walk/Run. Twenty-five percent of the pro-
ceeds from the race will be used to fund the national
grant program of the Komen Foundation and
seventy-five percent will remain in Arkansas to fund
breast cancer research, education, screening and treatment.
The Komen Foundation is a national organization
with a network of volunteers working through local
chapters and Race for the Cure events in 65 cities
throughout 35 states and the District of Columbia. It
is now the largest series of 5K runs in the United States.
Nancy Brinker established the Foundation in 1982 in
memory of her sister Susan Goodman Komen who
died of breast cancer at the age of 36.
The Arkansas race is underwritten by founding
sponsor TCBY and a host of other local and national
companies, organizations, and individuals. Start-up
times are 8 a.m. for the 5K and 8:15 a.m. for the 2K
Walk. The course will begin at the TCBY Plaza, Capi-
tol Avenue and Broadway in downtown Little Rock.
Registration fees are $12 per person through Sep-
tember 14, $16 per person September 15 - 20 and $20
per person on Race day. Barbara Graves Intimate Fash-
ions, Breckenridge Village Shopping Center, 1-430 at
Rodney Parham Road in little Rock will serve as Race
Headquarters this year for registration in person from
August 26 - September 20 and packet pickup Septem-
ber 16 - 20.
In addition to the race itself, a complimentary re-
ception will be held at the Arkansas Governor's Man-
sion on Friday, September 20, 4:30 - 6 p.m., 1800 Cen-
ter Street, Little Rock. All survivors, sponsors and race
participants are invited to attend. Also on Friday, Sep-
tember 20, 7-10 p.m., a Pre-Race Pasta Party and
Silent Auction will be held at North Oaks, Crystal Hill
Exit, North Little Rock, featuring the rock and roll
sounds of Johnny Roberts and the Rockets and the
extraordinary cuisine of Romano's Macaroni Grill. Tick-
ets are $18 for each registered participant and $35 for
all others.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board office should be contacted. There-
fore, we routinely suggest this list be shared with the
appropriate supervisory personnel and recruiters in
your office.
At the completion of the disciplinary period, the
nurse applies for reinstatement. Reinstatement is con-
tingent upon meeting the conditions set forth by the
Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY: Tune 12, 1996
"^Elizabeth Annette Loyd Hill, LPN 23071 (Little Rock/
Sheridan) REVOKED
"^Tana Lee Waugh Murphy, RN 37228 (Little Rock) Pro-
bation - 2 years
^Sheila Jane Brown, RN 44119 (Little Rock/Lonoke)
Probation - 2 years
*Linda Lucille Garrett, LPN 5585 (El Dorado) Proba-
tion - 2 years
DISCIPLINARY: Tune 13, 1996
*Kelly Suzan Driscoll, LPN 18641 (Sherwood) Suspen-
sion - 5 years; Fined - $3,100
“^Debra Kaye Abbott, LPN 12968 (McCehee/Rohwer)
Probation - 18 months
■^John Owen Jackson, RN 18232/CRNA 391 (West Mem-
phis) RN license renewable - $2,700 fine followed by 3
years suspension; CRNA Nat'l. Certification revoked;
AR CRNA unrenewable
*Mary Gaye Wilson, LPN 32623 (Jonesboro) Suspen-
sion - 2 years; Fine - $1,000
REINSTATEMENT:
^Jeannie Michelle Lewis, RN 39850 (Texarkana, TX)
*Joyce Yvonne Clayton Hammons, RN 31666 (Warren)
^Michael K. Ramsey, RN 22168 (Vilonia)
VOLUNTARY SURRENDER:
*Twylla Fontell Dihel, LPN 28842 (Salem) May 14, 1996
Volume 93, Number 3 - August 1996
121
AMS Newsmakers
(left to right) Ernest J. Ferris, M.D. and Simmie Armstrong, M.D.
Dr. Ernest J. Ferris, professor and chairman of
the Department of Radiology in the College of Medi-
cine at UAMS, was one of three recipients of the 1996
Distinguished Faculty Award. Dr. Simmie Armstrong
presented Ferris with the award. Ferris also was re-
cently elected the 1996 president of the Radiological
Society of North America.
Dr. Betty A. Lowe has been selected as the 1996
recipient of the Milton J.E. Senn Award & Lecture-
ship presented by the American Academy of Pediat-
rics. Dr. Lowe is a Fellow and past president of the
AAP, professor of pediatrics at UAMS, associate dean
for Children's Affairs at Arkansas Children Hospital
(ACH), and Harvey and Bernice Jones Distinguished
Chair in Pediatrics at ACH.
Dr. Nick J. Paslidis,
who was a resident of
Harvard Medical School,
was one of 50 outstanding
young medical profession-
als to receive the AMA/
Glaxo Wellcome Achieve-
ment Award. The award
recognizes exceptional lead-
ership abilities in medicine
or achievements in non-
clinical community activi-
ties. In addition, Paslidis
has completed a three-year
AMA certification of CME
and has been re-appointed
for the second year in the American College of Physi-
cians National Publications Committee.
Dr. I. Dodd Wilson recently received a special
recognition award to celebrate his ten years as Dean
of the UAMS College of Medicine. Dr. Joe B. Colclasure,
President of the Arkansas Caduceus Club, presented
Dr. Wilson with a plaque displaying the inscription
"In recognition of a decade of astute leadership, tire-
less commitment and dedicated service."
The Physician's Recognition Award is awarded
each month to physicians who have completed accept-
able programs of continuing education. Recipients for
the month of June 1996 are: Charles D. Barg, Little
Rock; Robert W. Donnell, Rogers; Darren L. Flamik,
Little Rock; Ricky W. Harrison, Russellville; David M.
Johnson, Searcy; Gregory J. Lewis, Conway; Charles
W. Logan, Little Rock; Salman N. Malik, Little Rock;
Timothy W. Martin, Little Rock; Tom L. Meziere, Little
Rock; Laura H. Nighorn, Fayetteville; Annette S. Slater,
North Little Rock; Rondal D. Smith, Blytheville; Kim
Graves, Dover; John G. Whitaker, Fort Smith; and
Charlotte R. Willis, Little Rock.
Send your accomplishments and photo
for AMS Newsmakers to;
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
NickJ. Paslidis, M.D.
122
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
New
Profile
George Givens Miller, M.D.
PROFESSIONAL INFORMATION
Specialty: Cardiology
Years in Practice: Two
Office: Fayetteville
Medical School: University of Texas Medical School at Houston, 1984
Internship/ Residency: University of Florida at Gainesville, 1985/1987
Volunteer Work: Worked for three years (1987-1990) in an indigent
health care clinic in Beaumont, Texas
Honors! Awards: Outstanding Physician Award, Herman Hospital, Houston, Texas, and the Joe G.
Wood Award for Excellence in Medicine.
PERSONAL INFORMATION
Children: George "Givens" Miller Jr., born August 1, 1989, great soccer player and Austin Daniel Miller,
born September 18, 1991, he's currently learning the alphabet
Date/Place of Birth: August 30, 1958 in Snyder, Texas
Hobbies: shooting sports - especially sporting clays & skeet/trap shooting. Also enjoy all forms of hunting
THOUGHTS & OTHER INFORMATION
Historical Figures I most identify with: Ben Franklin and George Patton
Worst habit: Work too hard and strong-willed
Best habit: Work very hard and strong-willed
Favorite junk food: hamburgers and corn dogs
Most valued material possessions: my shotguns
People who knew me in medical school, thought I was: wild and crazy
The turning points of my life were when: The first turning point was when I married the most
wonderfully loving woman. She has offered me unwaivering support, counsel, guidance and friendship.
The second turning point was my father's heart attack.
Nobody knows I: am very sentimental to my wife and family (like love story movies)
Favorite vacation spot: anywhere with my family
One goal I am proud to have reached: completing my interventional cardiology fellowship and
making Fellow in the American College of Cardiology
Favorite childhood memory: the houses I lived in
When I was a child, I wanted to grow up to be: a dentist, since 4th grade
One of my pet peeves: Inefficiency!!
First job: pumping gas at L&L Gas Station in Snyder, Texas
Worst job: cleaning oil storage tanks and hauling hay
One word to sum me up: Driven!
My life philosophy: Be ever vigilant and relentless in trying to impove intellectually, in relationships
and professionally
If you are interested in appearing in either the New Member Profile or Member Profile, contact Tina Wade at the Arkansas Medical
Society at (501) 224-8967 or 1-800-542-1058.
At Snell Prosthetic & Orthotic Laboratory,
we're not locked in by the way things used to be
We welcome the latest in worldwide technology,
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We've treated patients from as far away as Bosnia,
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patients with orthoses.
For prosthetics, our computer-aided design
and manufacture (CADjCAM) system allows us to
break down walls that previously existed in custom
manufacture. With CADjCAM, our staff is free to
create the most comfortable, precisely fitting
prosthetic devices yet available, truly breaking the
mold on traditional fittings.
Snell Laboratory was the first in Arkansas to
invest in this technology. Because homecomings
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Offices in Little Rock, Fort Smith, Russellville, Mountain Home, Fayetteville, and Hot Springs.
Little Rock (501) 664-2624 • Statewide Toll-free 1-800-342-5541
Special Article
Backflow Prevention Devices Required for
Medical Facilities on Many Public Water
Systems
Thomas L. Eans,
The Arkansas Department of Health has required
all public water systems to improve their provision of
safe drinking water by eliminating all cross-connections
from commercial and industrial establishments on their
systems. Few doctors are aware of this law and how it
affects them until they are served notice, and even
plumbers may have an insufficient understanding of
it and the valves it requires. There has been little pub-
licizing of this information by the municipalities and
the Health Department. This article is intended to in-
form clinic owners of their immediate and long term
responsibilities under this new law and how the costs
of it could be reduced, as well as to relate some as-
pects of the pre-existing State Plumbing Code for busi-
nesses of which these owners may not be aware.
Achieving and maintaining safe drinking water has
been established as a national priority. The
Cross-Connection Control Program resulted from
amended Rules and Regulations for Public Water Sys-
tems passed by the Arkansas Legislature to conform
to the National Primary Drinking Water Regulations.
A cross-connection is a physical connection between a
public water supply and either an unsafe or an objec-
tionable material. Each municipality was required to
pass an ordinance to have its water system institute
an inspection and elimination program for cross-con-
nections. The Arkansas Department of Health was
directed to assess penalties against any noncomplying
water system. There are no provisions specified for
requesting an exemption by either the water systems
or the users, although users can request an extension
from their local water system. The Program was re-
quired to be in place by 1/1/96.
The purpose is to protect the public water supply
from possible biological or chemical contaminants from
* Dr. Thomas L. Eans, FAAFP, of Little Rock, is a family physi-
cian with subinterest in occupational medicine.
businesses that may pollute the public water lines. The
pollution mechanism is through back pressure or back
siphonage from the connection due to occurrences of
reduction of pressure in the public water lines. The
method of hazard elimination is to require certain busi-
ness types to install a backflow prevention device on
their inlet water line or to disconnect the business
entirely from the public system. (Note this has noth-
ing to do with the sewage drainage lines. This comes
under other regulations.)
A business or industrial facility is said to have
backflow potential if: 1.) There are actual or potential
cross-connections; or 2.) There is intricate plumbing
which makes it impractical to ascertain whether or not
cross-connections exist; or 3.) There is an auxiliary water
supply which is, or can be, connected to the potable
water piping; or 4.) There is piping for conveying liq-
uids other than potable water, where that piping is
under pressure and is installed in proximity to potable
water piping. The most obvious examples are a water
hose connecting a faucet to a sink or container or run-
ning onto or under ground.
The Health Department recommended that each
public water system determine where backflow po-
tentials exist by inspection of the facilities. But to sim-
plify their adherence to the law, many water systems
have applied the decision universally to the Health
Department's list of suggested High Hazard facilities
without inspections and without specifying any ap-
peal process. Therefore, this decision is often applied
to facilities where backflow might happen under some
future changed physical circumstances regardless of
whether a cross-connection presently exists or has ever
existed. The Health Department's representatives do
support this action though. They emphasize this is a
very litigious society, and the proper use of a highly
reliable backflow device provides liability protection
Volume 93, Number 3 - August 1996
125
in the event some
drinking water con-
tamination occurs in
the vicinity of your
business.
All businesses
are categorized as
No, Low, Medium
or High Hazard Po-
tential. Table 1 de-
scribes these catego-
ries. Low Hazard
ones must be in-
spected by the wa-
ter system every
five years to clarify their classification. Medium Haz-
ard facilities are required only to have Double Check/
Stop Valves on their inlet water lines, and they will be
inspected by the water system every three years. High
Hazard facilities must have a Reduced Pressure Zone
(RPZ) valve or an Air Gap on their inlet water line,
and its function must be checked annually. (An Air
Gap is an impractical device for medical facilities and
will not be discussed here.) Medical clinics are cat-
egorized as High Hazard by many water systems as
Table 2 shows. They share this category with many
other businesses, a partial listing of which includes
golf courses, car washes, washaterias, sewage treat-
ment plants, hazardous waste facilities, farms handling
certain hazardous chemicals, commercial poultry
houses and livestock pens, mines, marinas, mortuar-
ies, schools with laboratories, bath houses and tattoo
parlours. (The Program applies only to businesses, but
the State Plumbing Code requires annually inspected
RPZ valves on residential fixed lawn sprinkler systems
also and screw-on vacuum breakers on all hose bibs.
Any old such fixtures must eventually be brought up
to that code. The Code also is relied on to cover other
facilities not in this program such as those for non-
commercial livestock and poultry.)
Medical clinics are assumed to have instrument
wash sinks, lab sinks or lab instruments where a po-
tential for a cross connection to a contaminant fluid
could exist. They also are assumed to have an x-ray
processor with its wash tank connected to a water fau-
cet and in the proximity to fixer and developer fluids
"under pressure" from their pumps such that a cross-
connection could exist. Whether through this analysis
or none at all, many, water systems have decided that
all clinics must have an RPZ valve, even if there are
no such lab instruments on plumbing or hoses on sink
faucets or any x-ray processors at all. If it has a proces-
sor being fed water through simple back flow protec-
tion devices on a loop well above the water inlet, and
the routine air gap gravity feed exists on its inlet spout,
the clinic still must have an RPZ valve.
126
This Program
does not require in-
ternal facility modi-
fications to protect
employees and cus-
tomers from being
exposed to polluted
water, but the State
Plumbing Code
does. This can be by
use of vacuum
breakers and check/
stop valves on the
inlet water line to the
apparatus in ques-
tion; eg x-ray processors. These cheaper devices can't
easily be checked for function and don't have to be,
but annual inspection and maintenance is required by
a licensed plumber. Replacement kits for their simple
internal parts are available. An RPZ valve has a com-
plicated design including connections such that a pres-
sure checking device can be attached to verify its proper
functioning of preventing backflow even under back
pressure. Replacement kits for RPZ internal parts are
available. The rules for its inspections are described below.
An RPZ valve must be in a loop between twelve
and thirty inches above the ground or floor. It may be
installed anywhere on the facility inlet water line be-
fore its first outlet. It can be inside the building to
prevent theft and freezing, but it should be realized
that it will open and may release water onto the floor
if the municipal system's pressure is lost. If placed
outside it is important to realize it is more susceptible
to freezing and subsequent breaking than a simple
water line above the ground would be. An insulated
cover can be placed over it. It can then have an electric
heat filament wrapped around the RPZ or a small light
bulb hung inside the cover to give better freeze pro-
tection. A concrete foundation can be poured to en-
able attachment of the cover to the ground to make
the valve and cover more secure from theft.
Insulated covers are available from plumbing sup-
ply houses for up to $500 depending on whether it
has a built-in heater. But you can have a sheet metal
worker build a simple one for $60-$90 and consider
having an electrician install power and a receptacle to
the site. The valve is usually purchased in a size ac-
cording to your inlet water line size. A 3/4" RPZ valve
costs $115-$200 and must be installed by a master
plumber, which will cost $75-$100. If concrete is poured
with attachments, that is extra. A strainer(Y clean-out)
that protects the RPZ from being blocked by water
line debris costs about $22. This is cost effective be-
cause if the RPZ has to be cleaned out, you will have
this expense plus the cost of retesting it then. An air
gap drain may also be offered to you. It is just a funnel
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table 1
Categorizing Businesses For Backflow Potential
Low Hazard — Any facility where the substance which could
backflow is objectionable, but does not pose an unreasonable
risk to health, and there is no possibility of backpressure in the
downstream piping system.
Medium Hazard — Same as Low Hazard except there is a
possibility of backpressure in the downstream piping system.
High Hazard — Any facility where the substance which could
backflow is hazardous to human health.
that is attached under
the valve to catch and
drain off the water if the
valve opens, and it costs
about $13 if desired. All
of these are available
from plumbing supply
houses.
After installation a
health department cer-
tified RPZ tester, who does not have to be a plumber,
is required to test the RPZ function. This costs $35-$85.
Your water department can give you a list of local
testers or may test it themselves. Copies of the test
form including your valve manufacturer's model and
serial number must be sent to your water department
and the Arkansas Department of Health. Annual test-
ing thereafter is required. Your water department usu-
ally will send a notice when this is due. Any repairs
on the device must be done by a plumber certified as
a Repair Technician for RPZ's.
This Program may appear to be arbitrary and with-
out sound justification as applied by many water sys-
tems to medical clinics and perhaps to other businesses
as well. Nevertheless, nonconformity is not a viable
option. The Program's Health Department representative
Arkansas Medical Society
Presents Workshops
CPT & ICD-9
For Physicians & Medical Office Staff
CPT for Family Practice
& Internal Medicine
Jonesboro - August 28
Springdale - October 1
El Dorado - October 15
CPT - General Surgery
Jonesboro - August 30
Springdale - October 3
El Dorado - October 17
ICD - for All Specialties
Jonesboro- August 29
Springdale - October 2
El Dorado - October 16
Watch for registration materials to be
mailed or contact the AMS
office at (501)224-8967 or
1-800-542-1058 for more information.
has recommended that
if you think there is an
inappropriate high haz-
ard categorization of
your business, you
could write to the
department's Division
of Engineering asking
them to review their
recommendations and
also write to your public water system asking them to
inspect your facility.
References;
1. Arkansas Department of Health Rules and Regulations
Pertaining to Public Water Systems, Revision Effective 4/23/95.
2. Arkansas Department of Health Minimum Standards for
a Cross-Connection Control Program, Revised April 1996.
3. Little Rock Water Department, notice received.
4. Heber Springs Water Department, notice received and
personal communication.
5. C & C Sheet Metal, 7102 Mabelvale Cutoff, Little Rock,
Arkansas, bid and construction.
6. Allied Plumbing Supply, 6300 Murray, Little Rock, Ar-
kansas, personal communication.
7. Various plumbers, personal communication.
ATTENTION
PHYSICIANS
The Arkansas Medical Society 1996
Membership Directory... a valuable source for
physicians, clinics and other health care profes-
sionals and businesses - is now available.
The directory lists all AMS members by city
with their address, phone and fax numbers and
specialty. The directory also contains informa-
tion such as the dates of AMS and AMA meet-
ings, county executives and specialty societies.
All AMS members will automatically re-
ceive one directory through the mail at no
charge.
Businesses, clinics and other health care
organizations may purchase the directory for
$50. Call (501) 224-8967 for rates on larger
quantities.
To order, send a check or money order to:
Arkansas Medical Society, 1996 Directory, P.O.
Box 55088, Little Rock, AR 722 1 5-5088.
Table 2
A Partial Listing of Some Water Systems' High Hazard
Category Of Backflow Potential
Medical Clinics Hospitals
Dental Clinics Nursing Homes
Chiropractic Clinics Laboratories
Veterinary Clinics
Volume 93, Number 3 - August 1996
127
^Professional ^Protection SxclusiYely since 1899
To reach your local office, call 800-344-1899.
■
Legally Speaking
Basic Rules for being
a Witness
David L. Ivers, J.D.*
In our last column we looked at how physicians
should prepare themselves for their role as expert wit-
nesses. Now it's time to discuss what to do when the
questions start coming. What follows are basic guide-
lines for any witness, lay or expert, followed by a word
of advice to experts in particular:
1. Tell the truth. No exceptions.
2. Listen carefully to each question before you an-
swer. Take your time. You will feel pressured to an-
swer quickly, particularly on cross examination, but
resist it. Make sure you understand the question. If
you do not, say so.
3. Answer only the question that is asked, usu-
ally with a "yes" or "no" answer if possible. Then
STOP. Do not volunteer information, as this may make
your answer objectionable or make you appear biased.
If an explanation is needed say so.
4. If an attorney tries to limit you to a "yes" or
"no" answer when you feel that an explanation is es-
sential, simply say you cannot answer the question
"yes" or "no." Usually the judge will let you explain,
but even if he or she doesn't, the jury will get the
message.
5. Don't guess and try not to preface your an-
swers with "I think" or "I believe." Give positive,
definitive answers whenever possible. Don't specu-
late. If you don't know, say so. Experts in particular
should be careful not to give medical opinions outside
their specialties.
6. Be wary of overbroad generalizations and ab-
solutes that may later come back to haunt you. Words
like "always," "never" and "nothing" carry red flags.
Instead of "Nothing else happened," say "That's all
that I recall." Don't let an attorney pin you down to
an exact answer if you are not sure. For example,
don't say you received a call from a patient at 11:15
p.m. if all you really recall was that it was somewhere
between 11 and 12.
7. If you realize your answer was wrong or un-
clear, correct it immediately. At an appropriate pause
* David L. Ivers, J.D., is an associate with Mitchell, Blackstock
and Barnes in Little Rock, general counsel for the AMS.
in the questioning, you can simply say, "I realize now
that something I said earlier needs to be corrected."
8. Always be polite, even if the attorney is not.
9. Beware of questions that paraphrase your an-
swers. These questions frequently begin, "Wouldn't
you agree that ...?" The lawyer may have changed
your meaning in ways you did not notice. You are
entitled to say that you would rather stand on your
answer and stick with it the way you worded it.
10. Stop instantly when an attorney objects or the
judge interrupts you. You will have an angry judge
on your hands if you try to sneak in an answer. Also,
the attorney who called you will often use an objec-
tion as a signal that danger is ahead, and many times
the objection will clue you in to the danger so that you
can avoid it.
11. If you are going to testify concerning records,
familiarize yourself with them. Be able to refer to them
easily if you need to do so while on the stand.
12. Don't be afraid to admit that you talked to a
lawyer or that you are being paid for your time. Good
attorneys always talk to their witnesses before they
testify, and it is accepted practice for experts to be
paid for their valuable time.
Experts Beware
Probably the hardest thing for any expert is to learn
to speak in plain English. Jargon is a part of any spe-
cialized field and the practitioners in those fields for-
get how completely foreign the language is to outsid-
ers. As one commentator has put it: Instead of say-
ing "Mr. Krueger suffered a lesion to the left motor
cortex of the cerebrum," say "Ed Krueger's head hit
the dashboard so hard that the impact literally caused
a tear on the side of his brain that has turned into scar
tissue." If you don't translate all the high-sounding
terms into everyday words, you might as well save
your breath and the court's time.
Sources;
1. Walter J. Matt and John E. Nagurney, "Suggestions
to Witnesses," Buffalo, N.Y., Bar.
2. James W. McElhaney, McElhaney's Litigation (1995).
Volume 93, Number 3 - August 1996
129
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Feature Article
Cover Story
Dramatic changes are taking place in the
Twin Cities
Tyler Hardeman*^
The Greater Little Rock area is on a roll. This should
be a good year to visit the Arkansas capital and its
twin. North Little Rock across the Arkansas River, to
see both cities as they undertake some dramatic
changes.
Thanks to the passage of a one year, one cent sales
tax combined with a previous $30 million bond issue.
Little Rock and North Little Rock are busily engaged
in revitalization efforts that will impact both sides of
the river.
In Little Rock, the Statehouse Convention Center
is being doubled in size, from its present 62,125 feet to
an expanded 112,520
feet. The convention
center will extend east-
ward from its present
site, thus requiring the
rerouting of the Main
Street Bridge over the
Arkansas River.
Farther to the east
on Markham Street, a
year-round farmer's
market has recently
opened. At the River Market one will find just about
anything from fresh herbs and flowers to fresh cus-
tom-cut and smoked meats.
Just beyond the River Market, the former Termi-
nal Warehouse, being renamed the Museum Center,
will serve as the new home of the Museum of Science
and History as well as offices and shops. In the same
area, Fones Brothers warehouse, which has stood va-
cant for many years, has been gutted and is being trans-
formed into the main branch of the Little Rock Public
Library.
* Tyler Hardeman is the travel editor for the Arkansas Depart-
ment of Parks and Tourism.
A pedestrian mall and grand entrance to Riverfront
Park is also part of the plans, as is an expansion of
facilities available for performers in Riverfront Park's
amphitheater.
Throughout 1996, a favorite stop for visitors to the
capital city will not be open for tours. The Old State
House, Arkansas' first state capitol building dating from
1836 has been shuttered to allow extensive repairs to
damaged walls, foundations and supports. Deteriora-
tion had advanced to the point where the building
was becoming dangerous, according to the Depart-
ment of Arkansas Heritage which maintains the build-
ing and its collections. The Old State House, widely
acknowledged as one of the finest examples of Greek
Revival architecture in the U.S., closed on April 1, 1996.
It will remain closed until renovation has been com-
pleted; an estimated 14 months with projected comple-
tion in June of 1997.
In North Little Rock, efforts by its Main Street pro-
gram are bearing fruit in several downtown blocks
where residences are being refurbished and upgraded.
Most excitingly, a new multi-million-dollar 18,000-seat
covered sports and entertainment arena is being
planned for an area between downtown and 1-30. There
are also plans for further development of the city's
An Historical Note
The origins of Little Rock date hack to 1722, when French explorer Benard
de la Harpe stepped ashore at an outcropping of rock on the south bank of the
Arkansas River. It was here that the native Quapaw Indians traditionally
crossed to the other side. La Harpe gave the outcropping - and thus the city
- its unusual name to distinguish it from Big Rock which rises upstream on
the North Little Rock side. History lies on every hand in the Twin Cities.
Volume 93, Number 3 - August 1996
131
Riverfront Park.
The Delta Queen Steamboat, which inaugurated
Arkansas River cruising in 1994, has returned for a
series of visits to the Twin Cities which began in May
and is scheduled to extend into November. New this
year is a visit to Tulsa's Port of Catoosa, the first time
in history that a steamboat has penetrated that far up-
stream on this major Mississippi River tributary.
But while all these new and exciting changes are
underway, there are still a number of traditional at-
tractions in the twin cities ready to welcome visitors.
The Arkansas Territorial Restoration, a collection of 14
buildings dating from the 1820 to 1840 period of settle-
ment is located at Third and Scott Streets in Little Rock.
Living history programs that bring to life episodes from
early territorial days are featured as well as an Arkansas
artists' gallery, craft shop and Cromwell Hall, where
items from the Restoration's permanent collection are
exhibited on a rotating basis.
Other attractions in Little Rock include; the Ar-
kansas Arts Center, located in MacArthur Park, offer-
ing a superb permanent collection of drawings, oils,
watercolors, and sculptures as well as traveling exhi-
bitions (there's also an acclaimed Children's Theatre,
a weekday luncheon restaurant and a gift shop); the
Museum of Science and History, located in the 1838
Tower Building next door until its move to the Mu-
seum Center, focuses on early Arkansans and the Na-
tive Americans who once occupied this land (the build-
ing was the birthplace of General Douglas MacArthur
while his father was commandant of the Little Rock
Arsenal); and the Decorative Arts Museum, where
contemporary crafts and other decorative items are
exhibited in one of Little Rock's earliest and most im-
pressive structures. The Decorative Arts Museum oc-
cupies the grand Pike-Fletcher-Terry mansion which
was built by noted early adventurer and author Albert
Pike. It also served as the boyhood home and subject
for Pulitzer Prize-winning Imagist poet John Gould
Fletcher. The State Capitol, a handsome, domed struc-
ture which commands a rise west of the downtown
area, offers audiotape and guided tours of legislative
chambers and changing exhibits.
The Children's Museum of Arkansas in the Union
Train Station offers a variety of imaginative exhibits
that encourage creativity and learning, and the Aero-
space Education Center with its IMAX Theatre brings
the excitement of space travel home to Arkansas audi-
ences. A six-minute film on the state and city is shown
with each featured big screen attraction.
The Quapaw Quarter reflects 19‘^ century life in
Little Rock. A grand collection of antebellum and Victorian
houses has been restored for offices, apartments and
single-family dwellings. The 1880 Italianate Victorian
Villa Marre at 14*’’ and Scott Streets is headquarters for
the Quapaw Quarter Association and a museum tour
home. If the house looks familiar, it's because it served
as the studio of the Sugarbakers in the hit CBS com-
edy "Designing Women."
On the cultural front, the capital city has much to
offer. Audiences have opportunities to enjoy first rate
theatre at the Arkansas Repertory Theater, Weekend
Theatre, Community Theatre of Little Rock and Murry's
Dinner Playhouse. There's also Ballet Arkansas, the
Arkansas Symphony Orchestra, which performs a so-
phisticated season of classical and pops concerts at
the Robinson Center Music Hall, and Wildwood Park
for the Performing Arts which is rapidly expanding its
offerings of music festivals and other special events.
Among Little Rock's park facilities are War Memo-
rial, featuring a public golf course, the Little Rock Zoo
and a stadium where the Razorback football team plays
several of its rivals each year; Rebsamen Park public
golf course; as well as Murray, Boyle and Allsopp parks
that offer a variety of outdoor experiences for hikers,
joggers, fishermen and picnickers. In addition, there
is Pinnacle Mountain State Park - an ecologically ori-
ented park on the edge of Little Rock's urban sprawl.
The park encompasses an Arkansas river landmark
which has served as a beacon for sailors since the first
explorers ventured upriver in the 1700s.
In North Little Rock, one will find a number of
attractions. "The Spirit" excursion boat operates from
a permanent dock in Riverfront Park providing
sightseeing and dinner cruises on the Arkansas River.
Wild River Country is another popular destination here,
where everything is themed to water activities.
The Old Mill, a recreation of 19*’’ century grist mills,
is tucked away in the hilly Lakewood residential area
north of 1-40. The picturesque mill is frequently used
as a backdrop for weddings and fashion shoots. It's a
great place for a family picnic with grounds maintained
by the Master Gardeners program.
A special treat in North Little Rock is enormous
Burns Park, one of the largest urban green spaces in
the country with over 1,500 acres. The park offers golf,
tennis, camping, hiking, carnival rides, a water slide,
ball fields, a motocross course, launching ramps and more.
There is much more to be found in the twin cities
as well as the entire state. For additional information,
contact the Heart of Arkansas Travel Association, PO
Box 3232, Little Rock, AR 72203, or the Arkansas De-
partment of Parks and Tourism, One Capitol Mall, Little
Rock, AR 72201, phone; 1 -800-NATURAL.
132
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Special Article
The State's Newest
Family Practice
Residency Program
Comes of Age
George M. Finley,
Rebecca Hyatt, B.S., C.P.M.’'”''
There's a new kid on the block, and it is South-
west Family Practice Residency and Clinic in Texarkana!
On June 27, 1996, the new clinic and residency pro-
gram - which is part of the University of Arkansas for
Medical Sciences, Area Health Education Center South-
west (AHEC-SW) - graduated its first class of family
practice residents (pictured above from left to right:
Christopher T. Smith, Paul D. Sarna, Shanna Hill
Spence and Jesse D. Moore). The new residency pro-
gram is positioned to serve southwest Arkansas and
northeast Texas with medical professionals for years
to come.
Background
Actually, the Clinic and Residency Program are
new, but AHEC-SW is not. AHEC-SW is part of
UAMS' statewide network of AHECs serving every
corner of the state, with locations in Eayetteville, Ft.
Smith, Jonesboro, Pine Bluff, El Dorado, and
Texarkana. The AHEC concept first entered the Na-
tional spotlight in 1970 when the Carnegie Commis-
sion published a report, "Higher Education & the
Nation's Health." AHECs were conceived as satellite
educational programs, developed as an extension of,
but at a distance from, major health sciences campuses.
The concept developed in answer to a grave need in
Arkansas and other states in the 1960s to retain physi-
cian graduates and for placement of physicians in ru-
ral areas. At that time only about 40% of UAMS graduates
remained in Arkansas, and many of those stayed in
the Central Arkansas area. Arkansans outside the cen-
tral area desperately needed better access to medical care.
Under the leadership of then-Governor Dale
* George M. Finley, M.D., is AHEC Director & Residency Di-
rector of AHEC-SW & Assistant Professor with the Dept, of
Family and Community Medicine, UAMS.
** Rebecca Hyatt, B.S., C.P.M., is Director of Development and
Research at AHEC-SW in Texarkana.
Bumpers, Roger Bost, M.D. who was Director of the
State Department of Human Services, and supporters
in the Arkansas General Assembly, the Arkansas
AHEC Program was born during the 1973 legislative
session. Within three years six centers were estab-
lished including AHEC-SW. The goals of the AHEC
program are:
"^To enhance the quality of primary health profes-
sions education by utilizing the best academic resources
available statewide.
*To improve the supply and distribution of Arkansas
health professionals, especially primary care providers.
“* **^To retain more UAMS graduates in Arkansas.
*To promote cooperation and coordination among
communities, health care providers, educational insti-
tutions, and health related organizations.
*To improve the health status of Arkansans by pro-
viding professional support and continuing education
for practicing health care providers and by offering
health education programs to the public.
Since 1975 AHEC-SW has developed and operated
a full service medical library which is comparable to a
medical sciences center with access to the National
Library of Medicine's computerized service. Biblio-
graphic Retrieval Service, and other resources for medi-
cal reference information. The library maintains a
collection of more than 1500 monographs, 200 medical
journal subscriptions, an audiovisual library, and has
access to the Hospital Satellite Network. The library
services are available to all health professionals and
students in the southwest area.
AHEC-SW has offered Continuing Medical Edu-
cation opportunities to over 300 area physicians, 14
hospitals, and 4 schools of nursing. Sponsored courses
are approved for AMA and AAFP CME hours. A va-
riety of conferences are scheduled by AHEC-SW and
attended by local and area physicians. AHEC-SW par-
Volume 93, Number 3 - August 1996
133
ticipates in the UAMS Rural Preceptorship Program,
the Family Medicine Clerkship and Junior & Senior
Medical Student Rotations.
Three Allied Health programs through UAMS
College of Health Related Professions are currently
offered at AHEC-SW for area students. Both Associ-
ate of Science and Bachelor of Science degrees are of-
fered in Radiologic Technology, with pre-professional
curriculum available at Texarkana College. The pro-
fessional portion of the curriculum is offered at AHEC
over twenty-four continuous
months of full-time
coursework. AHEC's De-
partment of Respiratory Care
offers an Associate of Science
degree over seventeen con-
tinuous months and CRTT-to-
RRT program over seven con-
tinuous months. Clinical ex-
perience accompanies class-
room and laboratory
coursework. The UAMS
College of Health Related
Professions offers a Bachelor
of Science Degree in Medi-
cal Technology with a senior
year internship available through
AHEC-SW at St. Michael's Health
Care Center. AHEC-SW in collaboration with the
UAMS College of Nursing participates in RN to BSN
to MNSc outreach programs which enables nursing
students to acquire a BSN off campus and obtain aca-
demic credit toward graduate level programs. A local
pharmacist also supervises UAMS pharmacy students,
teaches UAMS graduate courses, and instructs Respi-
ratory Care students in pharmacology.
AHEC-SW is included in UAMS' Compressed
Video Network which provides telecommunication
technology for distance learning which is the provi-
sion of basic and continuing education to distant stu-
dents. The technology allows interactive audiovisual
communication between individuals located at different sites.
Need for Residency
Although the other five AHECs in the state estab-
lished family practice residency programs from 1975
to 1980 with state funding, only AHEC-SW remained
without a residency program. The nine counties of
the AHEC-SW region had no direct access to a family
practice residency program.
The AHEC-SW program has always relied heavily
on its support from the medical community. There-
fore, the first step in a residency program feasibility
study was an assessment of medical community sup-
port. AHEC-SW faculty attended section meetings in
the specialties of family practice, surgery, medicine,
and pediatrics and the residency program proposal
was placed before these committees. There was over-
all agreement that the Texarkana area could support a
residency program. Physicians felt that the commu-
nity of Texarkana, as well as surrounding counties,
would benefit greatly from a residency program. More
than 50% of those attending the section meetings indi-
cated they would be willing to provide teaching assistance.
Both St. Michael Health
Care Center and Wadley Re-
gional Medical Center
were represented at the
various section meetings
and voiced their support. A
third Texarkana hospital.
Medical Arts, also embraced
and supported the residency
concept. Each section voted
unanimously to support the initia-
tion of a residency program. Thus,
a broad base of enthusiastic support
existed for the family practice residency
program in southwest Arkansas.
In support of the local assessment of
need, the federal designation of Medically
Underserved Area applied to part or all
of each county in the AHEC-SW region. All or part of
six counties in the region had the federal designation
of Health Professional Shortage Area. In 1991 Lafayette
County, Miller County's neighbor to the east, had the
dubious distinction from the Arkansas Department of
Health of being the number one priority in Arkansas
in need of health care services. Since 1987 four hospi-
tals in the AHEC-SW service area had closed — two in
Arkansas (Gurdon and Lewisville) and two in Texas
(Naples and Lone Star). Health care providers fre-
quently avoid or abandon practice locations due to lack
of hospital services and feelings of isolation. Con-
versely, hospitals suffer financial trauma and may even
close due to a shortage of providers. Therefore, local
training programs, the provision of adequate continu-
ing education, and professional support systems for rural
providers were essential.
Residency is Born
Dr. Herbert Wren, Director of AHEC-SW, set a
goal to establish a family practice residency program
at AHEC-SW. In October 1988 he hired Dr. George M.
Finley, who had a private family practice in Hope, to
spend 20% of his time working with the AHEC pro-
gram. In the early 1990's the two doctors won enthu-
siastic support from the hospitals and medical corn-
134 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
munity in Texarkana , as well as. Dr. Charles Cranford,
Executive Director of the state's AHEC program, the
directors at the other five AHECs in the state, and Dr.
Geoffrey Goldsmith, Chairman, UAMS Department
of Family and Community Medicine. Senator Wayne
Dowd, Representative David Beatty, and others
worked with then-Governor Bill Clinton and later.
Governor Jim Guy Tucker to obtain two years of fund-
ing from the Governor's office. Dr. Finley wrote a
three-year grant application to the federal Bureau of
Health Professions for a "Grant for Graduate Training
in Family Medicine" which was funded in 1993.
Plans were made for a clinic in Texarkana and for
residents to practice at Southwest Arkansas Compre-
hensive Care Clinic in Lewisville, operated by CABUN
Health Services, a Community Health Center at Hamp-
ton, Arkansas. Residents were recruited from the Jun-
ior Clerkship program already in place and provisional
accreditation was given. The first residents (four) came
aboard and the Southwest Family Practice Residency
and Clinic opened July 1993.
AHEC-SW has grown from six employees in 1988
to sixty-three (including residents and preceptors) in
1996. The number of residents in training increased
from four in 1993 to twenty in July, 1996. The pro-
gram now accepts six residents per year for the three-
year program, and specialists who want to re-train in
family practice. (Two are currently enrolled.)
Dr. Wren retired June 30, 1995, and Dr. Finley was
named AHEC-Southwest Director. Dr. Russell Mayo
is full-time faculty and six family practice physicians
are part-time faculty. The volunteer specialists who
provide placements for clinical rotations are essential
to the residency program, the health-related profes-
sions, and the Junior and Senior clerkships.
The Family Practice Residency offers residents ex-
cellent training in a broad-based curriculum that in-
cludes rotations in Adult Medicine, Pediatrics, Obstet-
rics, Emergency Medicine, Cardiology, Surgery, Diag-
nostic Imaging, Ortho/Sports Medicine, Family Prac-
tice, Gastroenterology, Cardiac Care/Pulmonary, Oph-
thalmology/ENT, Urology, Gynecology, Practice Man-
agement, Community-Oriented Primary Care (COPC),
and electives. A spirit of team work is essential for
the success of the program, and residents participate
in a number of weekly conferences, journal clubs, and
residents' meetings. The concepts of Family Practice
and total care of the patient are stressed in all areas.
The rich experiences and educational opportunities
offer the residents growth in personal and professional
maturity. Upon completion of the residency program,
the graduates are well-trained and equipped to enter
into any contract, attain appropriate privileges, and
provide care in basically any setting (rural, urban, aca-
demic). The physician will be able to move into any
medical community as an equitable partner, leader,
and professional.
AHEC-SW and the Southwest Family Practice Resi-
dency Clinic are located in the former Southern Clinic
Building. Renovations are currently in progress to
update the building, increase the number of exam
rooms, accommodate new computer technology, move
all the AHEC services under one roof, and provide
additional space for the rapid growth AHEC-SW has
experienced. In addition to the Texarkana clinic, sec-
ond- and third-year residents practice half a day each
week at Southwest Arkansas Comprehensive Care
Clinic (SWACC) in rural Lafayette County. This expe-
rience provides residents first-hand knowledge of ru-
ral practice as well as practical involvement in the
COPC model. COPC is a process in which health
problems of a defined population are systematically
identified and addressed, combining the principles of
primary care, epidemiology, and public health. In the
COPC rotation residents are able to assess the
community's health needs and develop an interest in
rural health with such activities as spending time with
the county construction superintendent, learning bea-
ver control to manage local flooding, water drainage
projects, local police work, the impact of farming on
injuries and chemical exposure, school health issues,
and sports health.
Expectations for the Future
What does this residency mean for southwest Ar-
kansas and the state as a whole? Studies have shown
that physicians frequently locate practices in areas
where their residency training occurred. This has cer-
tainly been the case with our first graduating class of
four physicians. Three are planning to practice in
Texarkana and one will join the community health clinic
at Augusta, Arkansas. The residency expects to pro-
vide physicians (and other health related profession-
als) not only in the nine-county region of AHEC-SW,
but also in the four-state area of northeast Texas, south-
east Oklahoma, and northwest Louisiana because of
the proximity of Texarkana to these areas. AHEC-SW
will also contribute to the pool of physicians trained
in the Arkansas AHEC network to provide placements
in both urban and rural locations over the state.
This residency provides a unique opportunity for
physicians to learn through the COPC model to ad-
dress health concerns of the community and to pro-
vide leadership in addressing and evaluating those
concerns. As the medical community participates in-
creasingly in managed care arrangements, prevention
and the health of the denominator population become
even more important. Physicians trained at AHEC-
SW are positioned to meet these new challenges.
Volume 93, Number 3 - August 1996
135
As Kflicrnirrs moved M esi. pioneers L L C
roiind.animuU as exotic as tJie
buffalo, prairie dogs, bears, beaverl/^ghorir
jliecp. cougars, volves and ratilesrfilMs.
The eagle became a national svTnbol. «. > \ i ' ‘
j, I he eagle became a national svTnbol. « ■; i ' ‘ ^ •
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hnnks again
tor more
information
on how
you can help,
call AHCAFat
(501) 221-3033
or (800) 950-8233
Arkansas Health Care
Access Foundation, Inc,
HF those physiciam who volunteer ^
r through the Arkansas Health J
' Care Access Foundation,
Thank You!
As you can see from a sampling of
i letters we have received, your
Ik involvement in our program is A
Wk appreciated and in many
cases life-saving.
THANK YOU FOR MAKING THE DIFFERENCE!
Scientific Article
Invasive Non-typeable Haemophilus
Influenzae Diseases in Children
Gordon E. Schutze, M.D.”^
Stephen F. Garrison,
Abstract
The current approach to patients with invasive
non-typeable H. influenzae disease is based upon past
experience with the type b strains. In areas where cli-
nicians cannot obtain typing information in a timely
manner, issues concerning treatment and prophylaxis
should be approached as if the patients were infected
with a type b strain. This approach will not change
until further information becomes available on inva-
sive non-typeable H. influenzae infections in children.
Introduction
Invasive disease due to Haemophilus influenzae has
become uncommon in the United States since the ad-
vent of the H. influenzae, type b (HIB) vaccines. These
vaccines however, are not effective in preventing ill-
nesses due to the non-typeable strains of this organ-
ism. Non-typeable H. influenzae are part of the normal
colonizing flora of the oropharyngeal cavity and are a
recognized cause of such local disease as otitis media,
sinusitis, and bronchitis in children and adults and
more invasive disease such as bacteremia and menin-
gitis in the newborn. Prior to the development of the
HIB vaccine, approximately 95% of cases of H. influenzae
meningitis and bacteremia in children older than 3
months of age were caused by the type b strains, while
the remaining 5% were due to the non-typeable strains.’
Recently however, non-typeable strains have been
found to be responsible for an increasing number of
cases of bacteremia and meningitis.^ Due to the suc-
cess of the HIB vaccine, a large proportion of invasive
H. influenzae disease encountered by clinicians today
will be due to the non-typeable strains. Clinicians
should be familiar with this organism and the proper
approach to the management of patients with inva-
sive disease.
Case Report
An 11-month-old white female presented for medical
* Gordon E. Schutze, M.D., is Assistant Professor of Pediatrics
and Pathology, UAMS, Arkansas Children's Hospital.
Stephen F. Garrison, M.D., is affiliated with St. Michael Health
Care Center and Collom and Carney Clinic in Texarkana, TX.
Volume 93, Number 3 - August 1996
evaluation with a chief complaint of fever, cough and
congestion. While in the waiting room, the patient had
a generalized tonic-clonic seizure which lasted approxi-
mately five minutes. Physical exam revealed a somno-
lent, febrile ( 103. 4°F) child with an inflamed right tym-
panic membrane. Laboratory evaluation revealed a
right middle lobe infiltrate on chest roentgenogram, a ■
white blood cell count of 23,100/mm’ with 50% neu- |'
trophils, 32% bands, 10% lymphocytes, 5% monocytes, J
2% atypical lymphocytes and 1% monocytes. Cere- :i
brospinal fluid evaluation revealed 0 white blood cells,
a protein of 20 mg/dl (range: 20 - 70 mg/dl), a glucose ;!;
of 77 mg/dl and a negative Gram stain. Past medical
history was remarkable for a sepsis evaluation and three ij
days of antimicrobial therapy at birth for persistent !'
leukocytosis and a 3 day hospitalization for a pneu-
monitis at 7 weeks of age. The patient had received
Hib TITER (Lederle-Praxis Biologicals) at 2 months of
age, and Tetramune (Lederle-Praxis Biologicals) at 4 I
and 6 months of age. !
The patient was admitted to the hospital and was '
administered cefotaxime (240 mg/kg/day). Non-typeable
Haemophilus influenzae was isolated from both blood
and cerebrospinal fluid culture. Repeat lumbar punc-
ture on the 3rd day of illness revealed 720 white blood
cells per mm’ with 98% neutrophils, a protein of 43
mg/dl, a glucose of 5 mg/dl and a negative Gram stain
and culture. The patient received a 14 day course of
cefotaxime prior to discharge. Immunologic evaluation
demonstrated a serum IgG level of 650 mg/dl as well
as normal serum levels for age of IgA, IgM, and IgG
subclasses. Audiologic follow-up demonstrated a mild
to moderate hearing loss bilaterally which was felt to
be related to middle ear effusions rather than senso-
rineural hearing loss. Typing results by the Texas De-
partment of Health verified the organism to be a
beta-lactamase producing non-typeable H. influenzae,
biotype III.
Discussion
Non-typeable H. influenzae are part of the normal
flora in the upper respiratory tract of children and have
been described to colonize from 20%-80% of children
137
J
at any one time. Recently however, the ability to dis-
criminate strains of non-typeable organisms by outer
membrane protein analysis have enabled investigators
to better understand the epidemiology of these organ-
isms. Investigators in New York recently found that
44% of children less than two years of age were colo-
nized with these organisms on one or more occasion
with a monthly prevalence rate of 11%. Children were
usually colonized with only one predominant strain
but could carry up to seven different strains at once.
The acquisition of this organism was greatest among
children less than one year of age.^
The major virulence factor of H. influenzae is the
production of capsular polysaccharide. Encapsulated
organisms (types a-f; predominately type b) have his-
torically been the causative agents for more severe in-
fections (e.g., bacteremia, meningitis) while the unen-
capsulated isolates (non-typeable) were frequently in-
volved with local disease (e.g., otitis media, sinusitis).
Although invasive infections with nontypeable strains
have been known to occur in healthy children, those
with facial or cranial bony defects, a history of chronic
otitis media, or immunoglobulin dysfunction or defi-
ciency were known to suffer more severe infections
with this organism. Our patient however, demon-
strated none of those risk factors.
The presentation of patients with non-typeable H.
influenzae bacteremia or meningitis is not unlike that
of other life threatening bacterial illnesses such as Strep-
tococcus pneumoniae or Neisseria meningitidis. There are
no clinical features that patients demonstrate when
infected with these organisms which set it apart from
the more commonly encountered bacterial pathogens,
therefore, clinicians must rely on the clinical labora-
tory for the proper identification of the organism. Pa-
tients with life threatening forms of this bacterial in-
fection should always be treated with systemic anti-
microbial agents. When selecting antimicrobial agents,
clinicians should be aware that similar to HIB, approxi-
mately 30% of non-typeable strains produce
beta-lactamase and are ampicillin resistant.'*
Cefuroxime, cefotaxime, ceftriaxone, and chloram-
phenicol are effective alternatives when patients are
infected with beta-lactamase producing organisms. In
patients with meningitis or overwhelming sepsis where
meningitis is of concern, cefuroxime should not be used
since previous studies demonstrated delayed cere-
brospinal fluid sterilization in patients with HIB men-
ingitis.’Once susceptibility information becomes avail-
able, antimicrobial therapy can be altered accordingly.
Due to the limited data about the treatment of in-
vasive disease due to the nontypeable strains, the
duration of therapy has been based upon prior experi-
ence with HIB. Clinicians who trained after the de-
cline of HIB disease should be reminded of the ag-
gressiveness of the Haemophilus organism. Unlike pneu-
mococcal or meningococcal bacteremia, patients with
H. influenzae bacteremia (including type b and
138
non-typeable isolates) have been demonstrated to de-
velop a secondary focus of infection in approximately
30% of cases treated with oral antimicrobial agents
alone.’ In patients with bacteremia therefore, intrave-
nous or intramuscular antimicrobial agents are usu-
ally used for 5-7 days before completing a 10 day course
with oral medications, while patients with uncompli-
cated meningitis receive 7-10 days of systemic therapy.
The majority of patients infected with this organism
will require hospitalization and close daily inspection
for the development of secondary sites of infection such
as bones, joints, or the pericardium.
The lack of the ability to obtain Haemophilus typ-
ing information in many community laboratories means
that treatment and prophylaxis decisions will be made
based upon incomplete information. Dexamethasone
therapy is recommended for patients with HIB men-
ingitis to prevent neurologic sequela, but has never
been studied for patients with non-typeable disease.*'
In areas where typing is not available however, pa-
tients with meningitis due to Haemophilus should be
approached as if they are infected with type b and
receive dexamethasone (0.6 mg/kg/d four times daily
for four days) and antimicrobial therapy. Likewise,
rifampin prophylaxis (20 mg/kg/d once daily for four
days) is indicated for family members of a patient with
invasive disease due to type b strains if there are in-
completely immunized children in the family under
four years of age, but there are no recommendations
for family prophylaxis when a patient is infected with
non-typeable organisms.® Without typing information,
prophylaxis decisions should be made as if the patient
was infected with HIB.
References
1. Murphy TF, Apicella MA: Nontypeable Haemophilus
influenzae: A review of clinical aspects, surface antigens, and
the human immune response to infection. Rev Infec Dis 1987; 9:1-15.
2. Deulofeu F, Nava JM, Bella F, et al: Prospective epidemio-
logic study of invasive Haemophilus influenzae disease in adults.
Euro J Clin Microbiol Infec Dis 1994; 13:633-638.
3. Faden H, Duffy L, Williams A, et al. Epidemiology of
nasopharyngeal colonization with nontypeable Haemophilus
influenzae in the first 2 years of life. Infect Dis 1995;172:132-135.
4. Faden H, Doern G, Wolf J, et al: Antimicrobial susceptibil-
ity of nasopharyngeal isolates of potential pathogens recovered
from infants before antimicrobial therapy: Implications for the
management of otitis media. Pediatr Infect Dis } 1994; 13:609-612.
5. Schaad UB, Suter S, Gianella-Borradori A, et al. A com-
parison of ceftriaxone and cefuroxime for the treatment of
bacterial meningitis in children. N Engl J Med 1990; 322:141-147.
6. Cortese MM, Goepp J, Aleido-Hill J, et influenzae bacter-
emia al. Children with Haemophilus initially treated as out-
patients: Outcome in 85 American Indian children. Pediatr
Infect Dts J 1992; 11:521 -525.
7. Feigin RD, McCracken GH, Klein JO. Diagnosis and man-
agement of meningitis. Pediatr Infect Dis J 1992;11 :785-814.
8. American Academy of Pediatrics. Committee on Infec-
tious Diseases. 1994 Red Book: Report of the Committee on In-
fectious Diseases. 23rd ed. Elk Grove Village, IL. American
Academy of Pediatrics, 1994:203-216.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Cardiology Commentary and Update
Tracy Dietz, M.D.*
J. David Talley, M.D.*
SECONDARY PREVENTION OE CORONARY ARTERY DISEASE
Atherosclerotic coronary artery disease is the lead-
ing cause of death of adults in the United States. It is
responsible for more than one of every four deaths.
Due to the decline in the death rate from acute myo-
cardial infarction (MI), there has been an increase in
the number of patients with chronic myocardial is-
chemia. Secondary prevention of coronary artery dis-
ease is directed at forestalling subsequent cardiac events
in patients who have already experienced at least one
acute ischemic event.
This review will focus on the recently published
guidelines for secondary prevention from the Ameri-
can Heart Association (Table 1).’
Cigarette Smoking. Cigarette smoking is a risk fac-
tor for the development of angina pectoris and MI and
increases the risk for recurrent MI and death. Survi-
vors of MI who continue to smoke have a recurrence
rate of MI and death twice that of patients who stop
smoking. This risk of a second cardiac event declines
rapidly after smoking cessation. Within three years of
stopping smoking, the risk of recurrent MI is approxi-
mately the same as ex-smokers and those who have
never smoked.^
Systemic Arterial Hypertension. There have been
no secondary prevention trials using behavioral or
medical therapy for lowering the systemic arterial blood
pressure after an initial cardiac event. However, based
on information from primary prevention trials, the
American Heart Association recommends a systolic
blood pressure goal of less than 140 mmHg for sec-
ondary prevention.
Cardiac Rehabilitation. A meta-analysis of ran-
domized clinical trials of cardiac rehabilitation after MI
with exercise as a major component showed that total
and cardiovascular mortality was reduced by approxi-
mately 25%.’ The American Heart Association recom-
mends 30-40 minutes of moderate intensity exercise
three to four times weekly.
Obesity. Although there are no randomized controlled
* Drs. Dietz and Talley are members of the Division of Cardiol-
ogy, Department of Internal Medicine, DAMS Medical Center.
clinical trials of weight loss in obese subjects to study
coronary artery disease endpoints, the American Heart
Association recommends intensive diet and physical
activity intervention in patients who weigh more than
120% of their ideal body weight.
Aspirin. Secondary prevention trials treating sur-
vivors of MI with aspirin have shown trends in reduc-
tion of cardiac events, but the trials were too small to
show statistical significance. The Anti-Platelet Trialists
Collaboration performed a meta-analysis of eleven tri-
als including more than 18,000 patients who received
anti-platelet therapy. Patients with prior MI had a 30%
reduction in risk of recurrent, non-fatal MI; a 25% re-
duction in total cardiovascular events; and a 12% re-
duction in total mortality (Table 2).'*
There is no benefit to adding dipyridamole or
warfarin to aspirin alone.’ The American Heart Asso-
ciation recommends the daily use of aspirin given in a
dose of 80-325 mg for all patients who have had a prior
cardiovascular event. Warfarin given in a dose to
achieve an International Normalized Ratio (INR) of
2. 0-3. 5 is recommended for patients unable to take
aspirin.
Estrogen Replacement Therapy. There have been
no randomized clinical trials of estrogen replacement
therapy used as secondary prevention. Recently how-
ever, a meta-analysis which included more than 2200
postmenopausal females 55 years of age or older has
been published. This study found that females with
coronary stenosis more than 70% diameter who took
estrogen had a 10 year survival of 97%, compared to
60% in females who had never used estrogen
(p=0.001).'^
Two other studies have suggested that estrogen
use protected against coronary artery disease progres-
sion.’’* Based on these trials, the American Heart As-
sociation recommends estrogen replacement therapy
in all post menopausal females who have no
contra-indication to its use. The adverse effects of es-
trogen therapy should be closely monitored.
Beta-Blockers. More than 35,000 patients have been
Volume 93, Number 3 - August 1996
139
Table 1; Guidelines for Comprehensive Risk Reduction in Patients with
Atherosclerotic Coronary Artery Disease
Risk Intervention
Recommendations
Smoking: Strongly encourage patient and family to stop smoking.
Goal - complete cessation Provide counseling, nicotine replacement, and formal cessation programs as appropriate.
Lipid management:
Primary goal
LDL<100 mg/dL
Secondary goals
HDL>35 mg/dL;
TG<200 mg/dL
Start AHA Step II Diet in all patients: <30% fat, <7% saturated
fat, <200 mg/dL cholesterol.
Assess fasting lipid profile. In post-MI patients, lipid profile
may take 4 to 6 weeks to stabilize. Add drug therapy according
to the following guide:
Physical activity:
Minimum goal
30 minutes 3 to 4
times per week
Weight management:
Antiplatelet agents/
anticoagulants:
ACE inhibitors
post-MI
Beta-blockers:
Estrogens:
Blood pressure
control:
Goal
<140/90 mm Hg
LDL<100 mg/dL
No drug therapy
LDL 100 to 130 mg/dL LDL>130 mg/dL
Consider adding drug Add drug therapy
therapy to diet as to diet, as follows:
follows:
^ Suggested drug therapy
TG<200 mg/dL
TG 200 to 400 mg/dL
TG>400 mg/dL
Statin
Resin
Niacin
Statin
Niacin
consider
combined
drug therapy
(niacin,
fibrate, statin)
If LDL goal not achieved, consider combination therapy.
HDL<35 mg/dL
Emphasize weight
management and
physical activity.
Advise smoking
cessation.
If needed to achieve
LDL goals,
consider niacin,
statin, fibrate.
Assess risk, preferably with exercise test, to guide prescription.
Encourage minimum of 30 to 60 minutes of moderate-intensity activity 3 or 4 times weekly
(walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily
lifestyle activities (eg, walking breaks at work, using stairs, gardening, household work).
Maximum benefit 5 to 6 hours a week.
Advise medically supervised programs for moderate- to high-risk patients.
Start intensive diet and appropriate physical activity intervention, as outlined above,
in patients >120% of ideal weight for height.
Particularly emphasize need for weight loss in patients with hypertension, elevated
triglycerides, or elevated glucose levels.
Start aspirin 80 to 325 mg/d if not contraindicated.
Manage warfarin to international normalized ratio=2 to 3.5 for post-MI patients not
able to take aspirin.
Start early post-MI in stable high-risk patients (anterior MI, previous MI, Killip class
II [S, gallop, rates, radiographic CHE]).
Continue indefinitely for aU with LV dysfunction (ejection fraction<40) or symptoms of failure.
Use as needed to manage blood pressure or symptoms in all other patients.
Start in high-risk post-MI patients (arrhythmia, LV dysfunction, inducible ischemia)
at 5 to 28 days. Continue 6 months minimum. Observe usual contraindications.
Use as needed to manage angina rhythm or blood pressure in all other patients.
Consider estrogen replacement in all postmenopausal women.
Individualize recommendation consistent with other health risks.
Initiate lifestyle modification - weight control, physical activity, alcohol moderation,
and moderate sodium restriction - in aU patients with bloocl pressure>140 mm Hg
systolic or 90 mm Hg diastolic.
Add blood pressure medication, individualized to other patient requirements and
characteristics (ie, age, race, need for drugs with specific benefits) if blood
pressure is not less than 140 mm Hg systolic or 90 mm Hg diastolic in 3 months or
if initial blood pressure is >160 mm Hg systolic or 100 mm Hg diastolic.
ACE indicates angiotensin-converting enzyme; MI, myocardial infarction; TG, triglycerides; and LV, left ventricular.
Reproduced with permission of the American Heart Association. Circulation 1995;92:2-4.
involved in long-term, placebo-controlled secondary
prevention trials using beta-blockers. In patients with
a prior cardiac event, beta-blocking agents reduce the
risk of recurrent MI by 27%, total mortality by 22%,
and sudden death by 32%.’ The American Heart As-
sociation recommends giving beta-blockers to all high
risk post MI patients (those with arrhythmia, left ven-
tricular dysfunction, inducable myocardial ischemia)
who have no contraindications, at 5-28 days and con-
tinuing therapy for at least 6 months.
ACE-inhibitors. A number of trials have studied
the use of angiotensin converting enzyme inhibi-
tors (ACE)-inhibitors in patients post MI. The
Survival and Ventricular Enlargement (SAVE) trial
randomized 2231 patients 3-16 days after sustain-
ing a Ml with an ejection fraction less than 40%
without symptoms of congestive heart failure to
placebo or captopril and followed them for 42
months. With the use of captopril, there was a
19% reduction in total mortality, a 21% reduc-
tion in cardiovascular death, a 37% decrease in
the development of severe heart failure, a 22%
reduction in the need for repeat hospitalization
for congestive heart failure, and a 25% decrease
in recurrent MI.’° Based on this and other trials,
the American Heart Association recommends be-
ginning an ACE-inhibitor early in the post MI
course in stable high-risk patients (anterior MI,
prior MI, or Killip class II-IV).
Lipid lowering therapy. The American Heart
Association advocates aggressive lipid lowering therapy
in patients with known atherosclerotic coronary ar-
tery disease. Studies have shown that dietary inter-
vention alone and in combination with pharmacologi-
cal therapy reduces the risk of total and cardiovascu-
lar mortality and other coronary events. Studies have
also demonstrated arrest of progression and regres-
sion of angiographically defined coronary lesions. The
American Heart Association recommends a Step II diet
in patients with known atherosclerotic coronary ar-
tery disease: a diet of less than 30% fat of which less
than 7% is saturated fat and less than 200 mg/day of
total cholesterol. All patients should have a fasting
lipid profile (total cholesterol, low and high density
lipoprotein subfractions, and triglycerides). Pharma-
cological therapy should be added as necessary to
achieve a low density lipoprotein less than 100 mg/dl,
a high density lipoprotein greater than 35 mg/dl, and
a triglyceride level less than 200 mg/dE.
Conclusions
There is dramatic benefit of prescribing behavioral
and pharmacological therapy aimed at preventing re-
current cardiovascular events in patients with known
coronary artery disease. With the high prevalence of
atherosclerotic coronary artery disease and the in-
creased number of patients with chronic myocardial
ischemia, it is critically important that physicians be
aware of and appropriately utilize strategies to pre-
vent recurrent events in their cardiac patients.
References
I. Smith SC Jr., Blair SN, Criqui MH, Fletcher GF, Fuster V,
Gersh BJ, Gotto AM, Gould KL, Greenland P, Grundy SM,
Hill MN, Hlatky MA, Houston-Miller N, Krauss RM, LaRosa
J, Ockene IS, Oparil S, Pearson TA, Rapaport E, Starke RD.
Preventing heart attack and death in patients with coronary
disease. AHA consensus panel statement. Circulation 1995;92:2-4.
2. Rosenberg L, Kaufman DW, Helmrich SP, Shapiro S. The
risks of myocardial infarction after quitting smoking in men
under 55 years of age. N Engl J Med 1985;313:1 51 1-151 4.
3. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Car-
diac rehabilitation after MI: Combined experience of ran-
domized clinical trials. J Am Med Assoc 1988;260:945-950.
4. Antiplatelet Trialists' Collaboration. Collaborative over-
view of randomized trials of antiplatelet therapy - 1: Preven-
tion of death, myocardial infarction, and stroke by prolonged
antiplatelet therapy in various categories of patients. Br Med
J 1994;308:81-106.
5. The EPSIM Research Group. A controlled comparison of
aspirin and oral anticoagulants in prevention of death after
MI. N Engl I Med 1982;307:701 -708.
6. Sullivan JM, VanderZwaag R, Hughes JP, Maddock V,
Kroetz FW, Ramanathan KB, Mirris DM. Estrogen replace-
ment and coronary artery disease. Arch Intern Med
1990;150:2557-2562.
7. Gruchow HW, Anderson AJ, BarboriakJJ, Sobocinski KA.
Postmenopausal use of estrogen and occlusion of coronary
arteries. Am Heart J 1988;45;954-963.
8. McFarland KF, Boniface ME, Hornung CA, Earhardt W,
Humphrier JO. Risk factor and noncontraceptive estrogen
use in women with and without coronary artery disease.
Am Heart J 1989;1 17:1209-1214.
9. Yusuf S, Wittes J, Friedman L. Overview of results of
randomized clinical trials in heart disease: 1. Treatment s follow-
ing myocardial infarction. J Am Med Assoc 1 998;260: 2088-2093.
10. SAVE Investigators. Effect of captopril on mortality and
morbidity in patients with left ventricular dysfunction after
MI. N Engl J Med 1992;327:669-677.
Table 2: Benefits of Secondary Intervention
in Patients with a Prior Cardiac Event
Total mortality
Aspirin
vF12%
Beta-blockers
4/22%
ACE-inhibitors
4/19%
Cardiovascular
death
-
-
4/21%
Recurrent
myocardial
infarction
vF30%
4/27%
4/25%
Severe
congestive heart
failure
-
-
4/37%
Abbreviation: ACE = angiotensin converting enzyme
Volume 93, Number 3 - August 1996
141
SOUTH DAKOTA PHEASANT HUNTING
with James R. Weber, M.D.
The Best Wild Pheasant Hunting in Ameriea
Make Reservations Now
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K you want to talk to an Army physician or visit an Ai'my hospital
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you. Call:
800-USA-ARMY
ARMY MEDICINE. BE ALL YOU CAN BE:
Information provided by the Arkansas Department of Health, Division of Epidemiology
Cyclospora
Infections
on the
Increase
Cyclospora cayetanensis is a recently characterized
coccidian parasite that has been associated with the
consumption of raspberries, strawberries and other
fresh fruits. The first known cases in humans were
diagnosed in 1977 and prior to 1996 only three out-
breaks of Cyclospora infection had been reported. In
May and June of 1996, however, at least 10 states re-
ported clusters or sporadic cases of the infection (there
have been no confirmed cases in Arkansas to date).
In one recent outbreak, 37 of 64 persons developed
Cyclospora infections after eating berries at a luncheon.
Cyclospora infects the small intestine and typically
causes watery diarrhea with frequent stools. Other
symptoms include loss of appetite, weight loss, stom-
ach cramps, nausea, vomiting, tiredness and low grade
fever. The incubation period is approximately one
week. If not treated, illness may last for a few days to
a month or longer.
Fecal oral transmission is possible but unlikely be-
cause excreted oocysts require days to weeks to sporu-
late and become infectious. The parasite may be trans-
mitted by swallowing oocyst found in contaminated
food or water. It is unknown whether animals can
serve as a source of infection for humans.
Oocysts can be identified in stools by examination
of wet mounts under phase microscopy, by use of an
acid-fast stain (oocysts are variably acid-fast) or the
demonstration of autofluorescence with ultraviolet
epifluorescence microscopy. Since a single negative
stool does not rule out the disease, three or more speci-
mens may be required. Stool samples may be submit-
ted to the Arkansas Department of Health in contain-
ers supplied by county health units (specifically re-
quest Cyclospora examination). There is no test for
the parasite on fruits and berries, so thorough wash-
ing of fruits and berries should always be practiced
prior to consumption.
Cyclospora infections can be treated with a seven-
day course of oral trimethoprim (TMP)-
sulfamethoxazole (SMX) (for adults, TMP 160mg plus
SMX SOOmg twice daily; for children, TMP 5mg/kg
plus SMX 25 mg/kg twice daily).
To report suspected cases or if you have any ques-
tions concerning Cyclospora, please call the Arkansas
Department of Health, Division of Epidemiology at
(501) 661-2893 during normal business hours.
Footnote: Portions of the above article were
adapted from "Outbreaks of Cyclospora cayetanensis
Infection - United States, 1996"; MMWR, Volume 45,
Number 25.
Volume 93, Number 3 - August 1996
143
Reportable Disease Update, Arkansas, 1995
The Division of Epidemiology, Arkansas Depart-
ment of Health (ADH) compiles data on the statewide
occurrence of notifiable diseases in Arkansas. Data in
this summary are derived from reports received by
the ADH from physicians, practitioners, nurses, medi-
cal care facility directors and laboratory personnel who re-
port cases of notifiable conditions listed in the "Rules and
Regulations Pertaining to Communicable Disease Con-
trol" adopted by the Arkansas State Board of Health
in 1977 pursuant to the authority conferred by Act 96
of 1913 (Arkansas statutes, 1947, Section 82-110) Section III.
The figure below shows the change (increase or
decrease) in the number of reported cases received in
1995 for selected diseases when compared to the aver-
age number of cases reported during the previous five
years (5-year mean). The data are shown as a ratio of
the number of cases reported in 1995 to the 5-year mean.
To obtain additional information on these and other
reportable diseases and conditions or to obtain a list-
ing and instructions on reporting communicable dis-
eases to the ADH, please call (501) 661-2893 or 1-800-
486-5400, ext. 2893 during normal business hours.
Change in Selected Disease Incidence in 1995
When Compared to Five-Year Mean
Diseases -#1995 cases Decrease Increase
AIDS* -274
Campylobacter - 153
Giardia- 131
Gonorrhea - 5437
H.influenzae - 6
Hepatitis A - 663
Hepatitis B - 83
Lyme Disease - 1 1
Meningococcal Inf. - 39
Pertussis - 59
Rabies, Animal - 52
Rocky Mtn Spotted Fever - 31
Salmonella - 338
Shigella- 176
Syphilis (P&S) - 474
Tuberculosis - 271
Tularemia -22
0 0.5 1 1.5 2 2.5 3
Ratio of Cases, 1995 / 5-year Mean (1990-1994)
*The 5-year mean for AIDS is 274
>
Do the
^ Thing!
We're always looking for interesting and informative ar-
ticles for The Journal. If you have a topic that you think
would be of interest to your peers, please submit it for
consideration to:
Managing Editor
The Journal of the Arkansas Medical Society
P.O. Box 55088
Little Rock, AR 72215-5088
(501)224-8967 (800)542-1058
Reported Cases of Selected Reportable Diseases in Arkansas
Profile for May 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
May 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1995
Total
Reported
Cases
1994
Campylobacteriosis
20
67
56
48
153
187
Giardiasis
7
46
44
35
131
126
Shigellosis
9
34
51
65
176
193
Salmonellosis
37
109
78
82
332
534
Hepatitis A
40
236
118
39
663
253
Hepatitis B
6
37
24
21
83
60
HIB
0
0
4
2
6
5
Meningococcal Infections
5
23
23
31
39
55
Viral Meningitis
0
11
7
18
31
62
Lyme Disease
4
9
4
8
11
15
Rocky Mountain Spotted Fever
0
2
6
4
31
18
Tularemia
2
5
9
10
22
23
Measles
0
0
2
1
2
5
Mumps
0
0
4
4
5
7
Rubella
0
0
0
0
0
0
Gonorrhea
396
2081
2047
2949
5437
7078
Syphilis
69
392
422
456
1017
1096
Legionellosis
0
0
5
5
5
16
Pertussis
0
3
14
19
59
33
Tuberculosis
28
90
89
83
271
264
Volume 93, Number 3 - August 1996
145
Arkansas HIV/AIDS Report
1983-1996
HIV In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501) 661-2387.
NOTE: County of residence may
change from date of HIV test to date
of AIDS diagnosis.
ID ^ ^ fci^ j - — ^
I Seviefi; ra
Pi?
Tm<. ' 1 Dallas|;:^ ^ I LPncomi^ ''■iAA_S
LUi g]
1 l>ew|
HIV+ CASES
REPORTED
□ 1 to 3
□ 4 to 49
■ 50 to 99
■ too to 1269
I County of residence at the lime of lest for the 3,603 Arkansans reported to be HIV+. (6/12/96)~|
HIV
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
Male
100
215
248
414
400
392
352
367
338
151
2,977
83
X
Female
8
26
37
68
85
81
94
90
91
46
626
17
Under 5
1
1
2
8
13
6
3
7
2
1
44
1
5-12
0
1
1
5
1
2
1
0
1
0
12
0
13-19
0
7
8
14
19
25
11
22
12
17
135
4
20-24
12
40
52
71
44
49
64
60
47
17
456
13
25-29
21
70
71
112
105
107
111
85
78
39
799
22
A
30-34
25
50
64
116
120
111
91
102
101
35
815
23
G
35-39
19
36
40
81
88
68
77
69
81
39
598
17
E
40-44
16
17
17
43
50
41
47
50
46
21
348
10
45-49
6
8
18
13
20
26
18
27
24
10
170
5
50-54
2
1
5
8
14
14
10
12
17
7
90
3
55-59
1
3
4
6
3
13
6
7
5
6
54
2
60-64
1
0
1
1
2
6
5
9
8
1
34
1
65 and older
4
2
1
2
3
5
2
7
7
4
37
1
R
White
87
170
174
328
298
293
278
259
260
96
2,243
62
A
Black
21
69
108
152
184
173
163
184
159
89
1,302
36
C
Hispanic
0
1
3
1
3
4
1
7
3
2
25
1
E
Other/Unknown
0
1
0
1
0
3
4
7
7
10
33
1
Male/Male Sex
64
137
141
243
246
261
242
229
157
53
1,773
49
Injection Drug User (IDU)
13
30
48
74
96
75
65
71
50
9
531
15
R
Male/Male Sex & IDU
19
23
24
32
30
34
26
23
25
8
244
7
Heterosexual (Known Risk)
5
25
26
59
64
68
100
94
56
19
516
14
s
Transfusion
5
5
4
6
8
10
0
2
2
0
42
1
K
Perinatal
1
1
2
8
13
8
4
7
0
0
44
1
Hemophiliac
0
0
6
18
5
6
2
3
5
0
45
1
Undetermined
1
20
34
42
23
11
7
28
134
108
408
11
HIV CASES BY YEAR
108
241
285
482
485
473
446
457
429
197
3,603
100
Arkansas Department of Health HIV/AIDS Surveillance Program
146
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1996
Fultonl
Carrolll
RandQlph|
Benton I
Baxterl
Marion I
Madison!
Washing!^
Independence)
J^^son|j
^ ■ rCleburn^:
Crawford!
Van Buren]
;:l"Poinsett^$
Jackson!
Franklin)
Crittenden!
ii Whllo|:
Sebastian]
Faulkner)
Woodruff
St. Francis]
I Seoul:
Pfainel
Pulaskil
Lonoke!
Monroe)
Saline!
Garland I
Montgom^
Grant]
Arkansas!
Jefferson!
Lincoln)
Sevier!
Nevada
Calhoun)
j-p Bradl^;
Ouachita)
Chicot[fj3
^ f j CnluiTib'i^
I La*iyP"^ (13]
::j Ashley[:;
Unionl
AIDS CASES
REPORTED
□
0
□
1 to 3
n
4 to 49
■
50 to 664
I Of the 3,603 Arkansans reported to be HlVt, 2,033 have been diagnosed with AIDS. (6/12/96)~|
AIDS In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with aIdS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: County of residence may
change from date of HIV test to date
of AIDS diagnosis.
Arkansas Department of Health HIV/AIDS Surveillance Program
Volume 93, Number 3 - August 1996
147
SPECIALIZE
IN AIR FORCE
MEDICINE.
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New Members
ARKADELPHIA
Rucker, Gari Mills, Pediatrics. Medical Education,
UAMS, 1993. Internship/Residency, Earl K. Long Medi-
cal Center, Baton Rouge, LA, 1994/1996. Board eligible.
BATESVILLE
Beck, James Foster, Hematology/Oncology. Medi-
cal Education, UAMS, 1990. Internship/Residency,
UAMS, 1991/1993.
BENTON
Hughes, Alan Wayne, Ophthalmology. Medical
Education, UAMS, 1990. Internship/Residency, UAMS,
1991/1995.
CROSSETT
Henry, William Warren, Jr., Family Practice. Medi-
cal Education, UAMS, 1993. Internship/Residency,
UAMS, AHEC-Pine Bluff, 1994/1996. Board pending.
DARDANELLE
Hartman, Ray, General Surgery. Medical Educa-
tion, Dalhousie, Halifax, Nova Scotia, 1984. Internship,
Dalhousie, 1985.
DE QUEEN
Jones, Thomas E.B., Family Practice. Medical Edu-
cation, University of Alberta, Calgary Alberta Canada,
1975. Residency, Memorial Hospital of Long Beach,
Calif., 1977.
FAYETTEVILLE
Ball, Charles S. Pediatrics. Medical Education,
UAMS, 1986. Internship, Arkansas Children's Hospi-
tal, 1989. Board certified.
FT. SMITH
Benson, Eric H., Radiology. Medical Education,
University of Texas Southwestern Medical Center,
Dallas, 1991. Residency, University of Texas Southwest-
ern Medical Center, 1995. Board certified.
Chan, Sheryl Evone, Pediatrics. Medical Educa-
tion, Oklahoma State University - College of Osteo-
pathic Medicine, Tulsa, 1993. Internship/Residency,
Tulsa Regional Medical Center, 1994/1996.
Lansford, Bryan Keith, Otolaryngology. Medical
Education, University of Oklahoma, Oklahoma City,
1990. Internship/Residency, 1992/1996.
Woodson, Alexa, Family Practice. Medical Educa-
tion, University of Oklahoma, Oklahoma City, 1992.
Internship/Residency, AHEC-Fort Smith, 1993/1995.
Board certified.
HOT SPRINGS
Herrold, Jeffrey William, Plastic Surgery. Medi-
cal Education, UAMS, 1984. Internship/Residency,
Fitzsimons Army Medical Center, Aurora, CO, 1985/
1994. Board certified.
JONESBORO
Chan, Kenneth, Neurology. Medical Education,
Southeastern University Health Sciences, North Mi-
ami Beach, EL, 1992. Internship, Dallas/Ft. Worth
Medical Center, 1993. Residency, Loma Linda Univer-
sity Medical Center, 1996.
Collins, Kevin Basil, Radiation Oncology. Medi-
cal Education, University of Oklahoma, Oklahoma
City, 1992. Internship, University of Oklahoma, 1993.
Residency, New York University, 1996. Board eligible.
Tagupa, Eumar T., Cardiology. Medical Education,
Indiana University School of Medicine, Indianapolis,
IN, 1989. Internship/Residency, Medical University of
South Carolina, Charleston, 1990, 1993. Board certified.
LITTLE ROCK
Bauer, David Harris, Plastic Surgery. Medical
Education, Vanderbilt University Medical School, Nash-
ville, TN, 1989. Internship/Residency, UAMS, 1990/
1994, and Vanderbilt University Medical Center, Nash-
ville, TN, 1996. Board certified.
Calicott, Timothy, Emergency Medicine. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
1994/1996.
Flanigin, Richard C., Psychiatry. Medical Educa-
tion, UAMS, 1992. Intemship/Residency, UAMS, 1993/1996.
Keplinger, Florian S., Physical Medicine & Re-
habilitation. Medical Education, University of Santo
Tomas, Manila, Philippines. Internship/Residency,
Univ. of Santo Tomas & UAMS, 1993/1996. Board eligible.
Meadors, John N., Radiology. Medical Education,
UAMS, 1988. Residencies, University of Tennessee
Medical Center at Knoxville, 1991 and 1995. Fellow-
ship, University of Texas Medical Branch Hospitals,
Galveston, 1996. Board certified.
Paslidis, Nick John, Internal Medicine. Medical
Education, University of Crete, Greece/Ross Univer-
sity, 1991/1988. Internship/Residency, University of
Texas Medical School, Houston, 1993/1995. Fellowship,
Harvard Medical School, 1996. Board eligible.
Volume 93, Number 3 - August 1996
149
Payne, Cheryl L., Radiation Oncology. Medical
Education, UAMS, 1991. Internship, UAMS, 1992.
Residency, Medical College of Virginia, 1996. Board
certified.
Van Noy, Joanna W., Pathology. Medical Educa-
tion, University of Mississippi Medical Center, Jack-
son, 1991. Internship, Parkland Hospital, Dallas, TX,
1992. Residency, University of Mississippi Medical
Center/UAMS, 1996.
MENA
Beckel, Ron W., Pediatrics. Medical Education,
UAMS, 1993. Internship/Residency, Arkansas
Children's Hospital, 1994/1996.
MONETTE
Verser, Michael Watson, Family Practice. Medical
Education, UAMS, 1993. Internship/Residency, AHEC-
NE, Jonesboro, 1994/1996. Board eligible.
NORTH LITTLE ROCK
Russell, Anthony E., Neurosurgery. Medical Edu-
cation, UAMS, 1989. Internship/Residency, 1990/1995.
Board certified.
Valley, Marc A., Anesthesiology-Pain. Medical
Education, Loma Linda University School of Medicine,
Loma Linda, Calif., 1984. Internship, White Memo-
rial, Los Angeles, 1985. Residency, Wilfuro Hall USAF
Medical Center, San Antonio, 1990. Fellowship, Johns
Hopkins, Baltimore, 1992. Board Certified.
ROGERS
Cooper, Scott S., Orthopedic Surgery. Medical
Education, UAMS, 1991. Internship, University of Ten-
nessee, 1992. Residency, University of Tennessee/
Campbell Clinic - Memphis, 1996. Board eligible.
RUSSELLVILLE
Miller, Mark E., Family Practice. Medical Educa-
tion, UAMS, 1993. Internship/Residency, AHEC-NW,
1994/1996. Board pending.
OUT OF STATE
Smith, Christopher Todd, Family Medicine. Medi-
cal Education, UAMS, 1993. Internship/Residency,
AHEC-Southwest, 1994/1996. Board eligible.
RESIDENTS
Alley, Jerri Lynn, Dermatology. Medical Educa-
tion, University of Kentucky, Lexington. Internship/
Residency, UAMS.
Cash, Paige Partridge, Obstetrics/Gynecology.
Medical Education, UAMS, 1996. Internship/Residency,
UAMS.
Danner, Christopher James, Otolaryngology.
Medical Education, University of Alabama at Birming-
ham, 1996. Internship/Residency, UAMS.
Gutierrez, Miguel Angel, Internal Medicine/Neu-
rology. Medical Education, Universidad Nacional
Autonoma de Mexico, 1979. Intemship/Residency, UAMS.
Hardin, Christopher Scott. Medical Education,
UAMS, 1996.
Hatley, Russell Eric, Family Medicine. Medical
Education, UAMS, 1996. Internship, UAMS.
Jussa, Murad M., Internal Medicine. Medical Edu-
cation, Dow Medical College, 1989. Fellowship, UAMS.
Kidd, Joseph Neil, General Surgery. Medical Edu-
cation, Baylor College of Medicine, Houston, TX 1996.
Residency, UAMS.
Markham, Larry Wayne, Internal Medicine/Pedi-
atrics. Medical Education, East Tennessee State Uni-
versity James H. Quillen College of Medicine, Johnson
City, 1996. Internship, UAMS.
Moix, Frank Martin, Jr., Internal Medicine. Medi-
cal Education, UAMS, 1996. Internship, UAMS.
Richey, Jason Dean, Family Medicine. Medical
Education, UAMS, 1996. Internship, AHEC-Jonesboro.
Roach, Milton Carey, III, Medicine/Pediatrics.
Medical Education, Texas Tech University School of
Medicine, Lubbock/ Amarillo, TX, 1996. Residency, UAMS.
Runion, Lance Keith, Diagnostic Radiology. Medi-
cal Education, UAMS, 1996. Residency, UAMS.
Smith, Daniel Fuller. Medical Education, UAMS,
1996. Internship, UAMS.
Smith, Matthew W. Medical Education, UAMS, 1996.
Sutterfield, Vikki Leigh, Family Practice. Medi-
cal Education, UAMS, 1996. Residency, AHEC-Fbrt Smith.
Wagner, Barbara R., Internal Medicine. Medical
Education, UAMS. 1996. Internship/Residency, UAMS.
SPRINGDALE
Cannon, Robert David, Anesthesiology/Pain Man-
agement. Medical Education, UAMS, 1990. Internship/
Residency, UAMS, 1991/1994. Fellowship, University
of South Carolina, 1995.
Levernier, James Edwin, Pediatric-Development/
Behavior. Medical Education, University of Minnesota,
Minneapolis, MN, 1968. Internship/Residency, Har-
bor General Hospital, UCLA, Torrance, Calif., 1969/
1973. Board certified.
STUDENTS
Jasen C. Chi
Twyla Rose Norsworthy
Randy Dean Walker
Barbara G. Woods
Angela Swain Krepps
Jamie Dyan Daniel
Mark Edward Moss
Paul Richard Gardial
Mark Bradley Baker
Margaret Anne West
Wilson H. Howe
Jason Ray Skinner
Ramona L. Rhodes
Jason Eli Farrar
Brett Thomas Krepps
Ronald David Hardin, Jr
Timothy Scott Harton
Michelle Leigh Rodgers
Tracy Leigh Crews
Martin Alan Hannon
150
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
Steven R. Nokes, M.D.
Eleanor E. Kennedy, M.D
W. Bradley Pierce, M.D.
History:
This 17-year-old female presented with exertional syncope. She had a positive head-up tilt, but also an abnormal
echo-doppler suggestive of right ventricular outflow tract dilatation. Electrophysiology revealed three beats of ven-
tricular tachycardia with a left bundle branch block configuration. An MR scan of the heart was performed.
Figure 3
Volume 93, Number 3 - August 1996
151
Arrhythmogenic right ventricular dysplasia
Diagnosis:
Arrhythmogenic right ventricular dysplasia.
Radiographic Findings:
The MR examination reveals transmural fatty infiltration of the free wall and apex of the right ventricular myocar-
dium with mild ventricular dilatation. The left ventricle is normal.
Discussion:
Arrhythmogenic right ventricular dysplasia is a rare cardiac disorder, first described in 1982 by Marcus, charac-
terized by fatty and fibrous replacement of the normal myocardium of the right ventricle. This produces arrhythmia of
right ventricular origin with subsequent syncope, cardiac pump failure and sudden death. The diagnosis is based on
the presence of a ventricular arrhythmia with a left bundle branch block configuration and morphologic changes or
motion abnormalities of the free wall of the right ventricle. The right ventricle is usually enlarged.
The gold standard for diagnosis has been angiography combined with biopsy. No quantitative criteria are avail-
able for echocardiography, although the diagnosis can be suggested, as in our case. Cardiac radionuclide angiogra-
phy yields precise and reproducible right ventricular ejection fractions, but the right wall cannot be evaluated directly.
Ultrafast CT can be used to make the diagnosis, but is not widely available and requires IV contrast. MR directly
demonstrates fatty or fibrous changes in the right ventricle, allows multiplanar direct acquisitions, does not require
contrast and reveals global and focal wall motion abnormalities using cine techniques.
References;
1. Auffermann W, Wichter T, Breithardte, et al. Arrhythmogenic right ventricular disease: MR imaging vs angiography. AJR
1993; 161:549-555.
2. Daubert C, Descaves C, Foulgoc JL, et al. Critical analysis of cineangiographic criteria for diagnosis of arrhythmogenic right
ventricular dysplasia. Am Heart J 1988; 115:448-459.
3. Hamada S, Takamiya M, Ohe T, Eda H. Arrhythmogenic right ventricular dysplasia
evaluation with electron-beam CT. Radiology 1993; 187:723-727.
Authors:
Editor: Steven R. Nokes, M.D. is associated with Radiology Consultants in Little Rock.
Contributor: Eleanor E. Kennedy, M.D. is associated with Arkansas Heart Group in Little Rock.
Contributor: W. Bradley Pierce, M.D. is associated with Radiology Consultants in Little Rock.
152
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
In Memoriam
William Wood Abbott, M.D.
Dr. William Wood Abbott, of Little Rock, died
Thursday, June 13, 1996. He was 75. He is survived by
his wife, Helen Wilson Abbott of Little Rock, and was
preceded in death by his first wife, Margaret Frame
Abbott, who died in 1971. He is also survived by two
daughters, Jane Abbot Bolding of De Land, Florida,
and Mary Ann Davidson of Little Rock; one son, Wil-
liam Wood Abbott, Jr., of Long Beach, Mississippi;
and five grandchildren.
James D. Armstrong, M.D.
Dr. James D. Armstrong, of Ashdown, died Sat-
urday, July 20, 1996. He was 60. He is survived by his
wife, Judy; three daughters and two sons-in-law,
Bonnie Armstrong and Andrew Lashus of Charles-
ton, S.C., Jimmie Anne Armstrong and Blane Graves
of Little Rock and Mary Armstrong of Atlanta, Ga.;
and two grandchildren, Gonnor and Laura Lashus.
Robert S. Bryles, M.D.
Dr. Robert S. Bryles, of Little Rock, died Wednes-
day, June 26, 1996. He was 57. Survivors include his
wife, Patricia; four children, Kirsten B. Alexander of
Maumelle, Robert M. Bryles of Atlanta, Ga., Mark B.
Bryles of Fayetteville and Gecellia R. Bryles of Little
Rock; one grandchild; one sister; one brother and five
nieces and nephews.
George H. Collier Jr., M.D.
Dr. George H. Gollier Jr., of Paragould, died Sun-
day, July 7, 1996. He was 51. He is survived by his
wife, Sheila; one son, George E. Gollier of Paragould;
three daughters, Emily Kueter and Leanne Felty, both
of Paragould, and Molly Gollier of Little Rock; mother
and stepfather, Mary Collier Buck and Joseph Wayne
Buck of Paragould; one brother, one sister and three
grandchildren.
Volume 93, Number 3 - August 1996
SPECIAL NOTICE:
The AMS’ P.O. Box
Number Has Changed...
As of July 22, 1996, the
Arkansas Medical Society's
post office box address is:
P.O. Box 55088
Little Rock, AR 72215-5088
PHYSICIAN
Part Time
Men’s Health Center of Little Rock
now hiring a Licensed Physician for
evaluation, treatment and follow-up of
small patient load. No weekends, holi-
days or call. Competitive Compensation
and Flexible Schedule. Send Resume/
C.V. to:
50 Midtown Park West
Mobile, AL 36606
or call:
334-471-9991
Attention Sam Kelley
THE ARMY RESERVE OFFERS UNIQUE AND
REWARDING EXPERIENCES.
As a medical officer in the Army Reserve you will be offered a
variety of challenges and rewards. You will also have a unique
array of advantages that will add a new dimension to your
civilian career, such as:
• special training programs
• advanced casualty care
• advanced trauma life support
• flight medicine
• continuing medical education programs and conferences
• physician networking
• attractive retirement benefits
• change of pace
It could be to your advantage to find out how well the Army
Reserve will treat you for a small amount of your time. An Army
Reserve Medical Counselor can tell you more, call collect :
800-USA-ARMY
ARMY RESERVE MEDICINE. BE ALL YOU CAN BE!
A strong, effective leader... A caring, trusting physician...
A good, loyal friend. . . You will be greatly missed.
In Fond Memory of AMS
Immediate Past President
James Armstrong, M.D.
Each of us must
remember our first and
foremost responsibility
is to our patients.
Regardless of practice
arrangements, govern-
ment regulations, or
other outside influences,
our primary duty is to
provide compassionate
and quality health care
to those who seek our
help.
Excerpt from Dr. Armstrong's
1996 AMS Annual Session Speech
on May 4, 1996.
James Armstrong, M.D., 1995/1996 President of the Arkansas Medical Soci-
ety, died Saturday, July 20, 1996. He was 60. Graveside services were held at 10
a.m., Monday, July 22, 1996, in Ashdown. Dr. Armstrong was a member of the
Arkansas Medical Society for 34 years and had earned the respect and affection
of the members of the Society and staff. Dr. Armstrong was serving on the
Executive Committee at the time of his death. He served on the Council from
1982 until he was elected president-elect in 1994.
Dr. Armstrong was the director of and a family physician at Ashdown Clinic
since 1965 and the Little River County Coroner since 1968. In addition, he was
the Little River County Health Officer and had served in many positions includ-
ing chief of staff at Little River Memorial Hospital.
Dr. Armstrong earned a bachelor's degree with honors in chemistry from
Hendrix College in 1957, and in 1961 graduated from the University of Arkansas
School of Medicine. He completed a rotating internship at the Hillcrest Medical
Center in Tulsa, Oklahoma in 1962 and then went on to complete post-graduate
studies at Peter Brent Brigham in Boston, Massachusetts; Parkland Hospital in
Dallas, Texas; the University of Kansas in Kansas City; and the University of
Arkansas in Little Rock.
In 1964, Dr. Armstrong earned his original certificate from the American
Board of Pamily Practice. He was a charter member of the American Academy of
Pamily Practice and the Arkansas Academy of Pamily Practice, where he also
was a past director.
He served on the Arkansas Poundation for Medical Care's Board of Directors
from 1980 to 1994 and as chairman of the board from 1991 to 1994. He served as
an Arkansas delegate to the American Medical Peer Review Association and the
Tri-Regional Review Conference.
He was a member of the Board of Directors of the Bank of Ashdown and a
member of the Pirst United Methodist Church of Ashdown. Survivors include
his wife, Judy; three daughters; two sons-in-law, and two grandchildren. In lieu
of flowers, the family asks that memorials be made to the Salvation Army or to
a charity of your choice.
Volume 93, Number 3 - August 1996
155
Things To Come
September 6-7
3rd Annual Current Topics in Cardiothoracic
Anesthesia. Washington University Medical Center,
St. Louis, Missouri. Sponsored by the Office of Con-
tinuing Medical Education, Washington Univ. School
of Medicine. For more informarion, call 1-800-325-9862.
October 5-6
Lymphomas and Leukemia; Clinical Advances,
Basic Science and Supportive Care Issues. J. Bennett
Johnston Building, Tulane University Medical Center,
New Orleans, LA. Sponsored by Tulane University
Medical Center, Tulane Cancer Center, Center for Con-
tinuing Education and Nursing Resource Center. For
more information, call (504) 588-5466 or 1-800-588-5300.
October 9-13
Infectious Disease '96 Board Review Course - A
Comprehensive Review for Board Preparation. The
Hyatt Regency Hotel, Washington, D.C. Sponsored
by the Center for Bio-Medical Communication. For
more information, call (201) 385-8080.
October 17 - 19
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
November 1-3
New Developments in the Pathogenesis & Treat-
ment of NIDDM (non-insulin dependent diabetes
mellitus). Radisson Resort, Scottsdale, Arizona. Spon-
sored by the American Diabetes Association of Ari-
zona and the National Institute of Diabetes and Di-
gestive and Kidney Diseases. For more information,
call (602) 995-1515.
November 14 - 17
15th Annual Scientific Meeting - Pain and Dis-
ease; Causes, Consequences, and Solutions. Sheraton
Washington Hotel, Washington, DC. Sponsored by the
the American Pain Society. For more information, call
(847) 375-4715.
November 20 - 24
90th Annual Scientific Assembly - Yesterday's
Caring with Today's Technology. Baltimore Conven-
tion Center, Baltimore, Maryland. Sponsored by the
Southern Medical Association. For more information,
call (800) 423-4992 or (205) 945-1840.
December 7
Cardiology Seminar. Washington University Medi-
cal Center, St. Louis, Missouri. Sponsored by the Of-
fice of Continuing Medical Education, Washington Uni-
versity School of Medicine. For more information, call
1-800-325-9862.
156 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Keeping Up
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category I of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/ General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INEIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Spine Center Conference, 1st Wednesday, 7:00 a.m.. Southwestern Bell/Arkla Room. Light Breakfast provided.
Urology Grand Rounds, September 17th and November 5th, 5:30 p.m.. Southwestern Bell/Arkla Room, Refreshments provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
As an organization accredited for continuing medical education by the Accreditation Council for Continuing Medical Education, the
University of Arkansas for Medical Sciences certifies the following continuing medical education activities meet the criteria for Category I
of the Physician's Recognition Award of the American Medical Association.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular &t Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Volume 93, Number 3 - August 1996
157
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTHSearcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GURadiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS Hospital
OB/GYN Fetal Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Gonference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Gonference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology/Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
158
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Thursdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroradiology Conference, 3rd Friday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Gynecologic Malignancies, 3rd Thursday every other month, 7:00 a.m., various area hospitals
Neuro-Radiology Conference, 1st & 3rd Thursday, 12:00 noon, Wadley Regional Medical Center
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 3 - August 1996
159
Advertisers Index
Advertising Agencies in italics
AMS Benefits back cover
Arkansas Blue Cross & Blue Shield 1 19
Autoflex Leasing inside front
Freemyer Collection System 1 19
The Medical Protective Company 128
Williams Marketing Services
Riverside Motors, Inc 130
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory 124
Strategic Marketing
State Volunteer Mutual Insurance Company 114
The Maryland Group
Southwest Capital Management 1 17
Marion Kahn Communications, Inc.
UAMS-AHEC Program &
Tulane Medical Center inside back
U.S. Air Force 148
BJK&E Specialized Advertising
U.S. Air Force Reserve 1 13
HMS Partners, Inc.
U.S. Army Active 142
Young & Rubicam, Inc.
U.S. Army Reserve 154
Young & Rubicam, Inc.
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Lee Abel, M.D.
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Alex Finkbeiner, M.D.
Pediatrics
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THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
Volume 93 Number 4 September 1996
CONTENTS
FEATURES
164 The Building of the Land of Opportunity - Editorial
Ben N. Saltzman, M.D.
167 Medicine in the News
Health Care Access Foundation Update
News Bites from the AMA
Deaths from SIDS Drop jj
New Service for Healthcare Professionals J
As First Year of MPH Program Ends, Arkansans Describe Impressions, |
Experiences, Plans “I
i
173 New Member Profile llj
William L. Paul, M.D. J
175 Assessing Clinical Skills of Medical Students - Special Article S”
Jeanne K. Heard, M.D., Ph.D. L
Ruth Allen, Ph.D. j
Patrick W. Tank, Ph.D. |
Gerald /. Cason, Ph.D. |
Mary Cantrell i|
Richard P. Wheeler, M.D. (
181 Breastfeeding in Arkansas: Trends in the Northeast Region and
Physician Self Assessment Quiz - Special Article
Mark Albey, M.D.
Sherry Rickard, R.N., l.B.C.L.C.
Warren Skaug, M.D.
185 Breastfeeding in Arkansas: The Role of the Arkansas
Department of Health - Special Article
Malinda O. Webb, M.D.
Susan M. Ellerbee, Ph.D., R.N.C.
DEPARTMENTS
171 AMS Newsmakers
191 Cardiology Commentary & Update
195 State Health Watch
198 Arkansas HIV/AIDS Report
200 New Members
203 Radiological Case of the Month
211 In Memoriam
212 Things to Come
213 Keeping Up
Cover photograph taken by A.C. Haralson of the Arkansas Department of Parks & Tourism.
A
Editorial
The Building of the Land of Opportunity
Ben N. Saltzman, M.D.*
Note: Dr. Saltzman came to Mountain Home, Arkan-
sas, after acquiring a BA and an MA in Psychology and an
M.D. in Medicine, all at the University of Oregon; a Gen-
eral Internship & Residency at Gorgas Hospital in Ancon,
the Canal Zone; and four years of active duty in the Army of
the United States detached to the Panama Canal Depart-
ment of Health to care for the health of the Civilian popula-
tion of Gamboa in the Canal Zone Dredging Division Area.
An editorial detailing this period of Dr. Saltzman' s life ap-
peared in the March 1996 issue of The Journal.
When considering moving to Mountain Home, I
was informed that the town had served as the base for
the construction of a large hydroelectric dam named
the Norfork Dam and that people, usually from the
Chicago area, were moving into the region to fish and
hunt. I was also informed that plans were afoot to
build another dam in the Bull Shoals area which would
also help the growth of the region, and I would have
the opportunity of growing with the area. Somewhere,
I had read that Arkansas was known as the Land of
Opportunity.
Dr. Elisha Gray of Mountain Home had contacted
Dr. Rector Hooper in Batesville seeking a physician to
take his place in Mountain Home because of his per-
sistent poor health and the fact that he had reached
the age of 65 and could no longer function as before.
Hooper, who just happened to be married to my wife's
sister and also served as my mentor while at Gorgas
Hospital was probably influenced by his wife who
missed her sister. At any rate, I accepted the position
and came to the land of opportunity to enter a rural
practice.
I had been promised many things which were not
forthcoming, such as a clinic to practice, a new car for
transportation and a place to live. The house calls and
deliveries in the rural cabins were overwhelming, and
there was no hospital to carry on a semblance of mod-
ern practice.
Following a period of frustration, my resentment
was palliated by the goodness of the people whom 1
served. 1 was rapidly invited into several organizations
and made to feel completely at home, particularly when
I made house calls. In general, there was considerable
poverty. The only paved road into the town was a
* Dr. Saltzman is a retired family practitioner from Mountain
Home. He is a member of the AMS Fifty Year Club and the
editorial board for The Journal of the Arkansas Medical Society.
164
Federal highway. The only paved street in the town
was around the square because a new Courthouse had
just been completed in the center. My office calls were
two dollars. Some people thought this was much too
high since some of their previous doctors charged only
75 cents. My collections averaged out about 50 per-
cent. My house calls and deliveries often took me into
areas that were death to my car's butyl rubber tires of
the period. The manager of the service station that 1
frequented thought it was funny that I would ruin a
couple of tires, not get paid a cent and then go out
again to receive the same type of treatment.
I served on the city council for a period of seven
years. The AMA recommended that doctors get in-
volved in the activities of the citizens and prove that
doctors are human. The idea was a good one but it
sometimes backfired. As a physician, 1 was asked to
contact owners of property that the city needed for
the expansion of a much needed sewage or water sys-
tem. Sometimes I had to get the Sheriff to accompany
me. Sanitarians were not available at that time for the
small towns. I had nightmares when it came to con-
demning septic tanks.
In a period of 27 years, I tried four times to get the
streets paved during my period of active practice. I
felt that the dust and gravel were unhealthy. The pav-
ing that was attempted at that time usually lasted about
two weeks.
Gradually, as more people moved into the com-
munity from larger cities, more attention was directed
toward improving the environment. Our schools be-
gan to take pride in their accomplishments. Mountain
Home usually ranked high in accreditation.
However, all was not well with my practice. I was
able to acquire a partner who was a hard worker and a
conscientious physician, and the people liked him. We
worked well together and never had any personal dif-
ficulties. I had a few scares isolated many miles from
immediate help, particularly from the obstetrical stand-
point. We initiated an effort to utilize a pair of beds for
obstetrical patients who lived a long distance from
Mountain Home. But 1 knew that we needed a hospital.
I made several attempts to interest the City Coun-
cil and the Chamber of Commerce into building a small
hospital, but no one felt we could afford it. They were
probably correct, but I couldn't go on the way we were.
I finally decided to enlarge our clinical facilities as many
of the physicians in the larger communities had done
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
fairly successfully. We built a small seven-bed facility
with a delivery room and a surgery by cashing in my
life insurance policy, getting a loan from my parents
and finally being offered a substantial loan from the
Peoples Bank. We set an opening date so people would
have an opportunity to see what we had to offer. Be-
fore the opening day, every bed was full including a
patient in labor on the X-ray table. Those were excit-
ing days. Within three years it became necessary to
add more beds.
More doctors began to move into the community,
and more and more people moved into Mountain
Home and neighboring territory.
One day, as he watched the expanded building
program, my attorney and excellent personal friend,
Tom Tinnon remarked, "Ben, mark my words, this
community will in the near future become a medical
center for northern Arkansas."
One of our retirees, a very active man in his 70's
and a real worker in the Chamber of Commerce, ap-
proached me with a suggestion - he felt that we needed
a general hospital. He had talked to others along this
line and decided to ask me about my feelings in the
matter since he knew that 1 had a major investment in
my clinic.
He had talked to others and there seemed to be
general interest. He wondered if 1 would object to his
talking to the community at large. 1 informed him that
I liked the idea so much that 1 would turn over most
of my hospital beds and other equipment to a new
hospital until it could acquire all the things it needed.
He then asked me if 1 would head a steering commit-
tee to deal with the architects and builders. 1 informed
him that I would be happy to do so.
1 did have trouble with the architects who wanted
to limit beds to 30 in number. We finally agreed on the
building of a single large Ward Room that could be
converted for bed space if needed.
Baxter General Hospital opened as an acute care
hospital in November of 1963 with 39 beds and an
active staff of four physicians. Today, Baxter County
Regional Hospital is an ultramodern 191-bed facility
which has grown from a small rural hospital to a re-
ferral medical center for northern Arkansas and south-
ern Missouri. It is recognized statewide for its effi-
ciency of operation and its provision of out-patient
services. Its operating costs are the lowest in the state
and probably the country, since Arkansas' costs are
the lowest in the United States. Today, the hospital
has an active staff of 64 physicians in every specialty
except neurosurgery and major cardiac surgery. Ex-
cept for recuperative beds, all rooms are single beds.
Having spent almost twenty years in Little Rock
in many satisfying medical activities, 1 had not no-
ticed the many changes that had taken place in Moun-
tain Home until 1 returned upon retirement in 1991.
With beautifully paved streets, curbs and gutters, beau-
tiful, well kept parks, excellent schools and even su-
perior athletic events, this community certainly has
become the Land of Opportunity. I wish Tom Tinnon
could have lived to see it now.
Some simple logic...
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green,
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Medicine in the News
Health Care Access Foundation
As of August 1, 1996, the Arkansas Health Care
Access Foundation has provided free medical service
to 11,393 medically indigent persons, received 21,197
applications and enrolled 41,516 persons. This program
has 1,736 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
News Briefs from the AM A
Physician-Assisted Suicide (Board Report 59) - In
a nearly unanimous vote, the AM A reaffirmed its ada-
mant opposition to physician-assisted suicide. In ad-
dition, it called for comprehensive physician educa-
tion in caring for patients at the end of life. The AMA's
position on physician-assisted suicide is grounded in
ethical policy set by its Council of Ethical and Judicial
Affairs (CEJA). CEJA authors and continuously main-
tains the AMA's Code of Medical Ethics, which has
protected the patients of American for nearly 150 years.
Mandatory HIV Testing of Pregnant Women (Reso-
lution 425) - Relying heavily on statistics showing that
treating HIV-positive women during pregnancy re-
duces by two-thirds their risk of infecting their un-
born children, the AMA endorsed mandatory testing
and appropriate counseling of all pregnant women and
newborns for HIV.
Ultimate Fighting (Resolution 405) - The AMA
voted overwhelmingly to oppose ultimate or extreme
fighting contests, which promoters brazenly advertise
as the "bloodiest, most barbaric show in history." The
AMA passed new policy that will strongly urge states
that have not yet banned this activity to pass a law
doing so in order to protect the lives of participants.
The AMA also plans to study the feasibility of federal
or state restrictions on the broadcasting of these events.
Fatigue, Sleep Disorders and Motor Vehicle Crashes
(CSA Report 1) - America's doctors are taking the lead
against what some call America's "hidden nightmare."
A report passed by the AMA's policy-making House
of Delegates indicates that the economic, medical and
public health costs of sleep-related problems are ig-
nored. This is particularly alarming because drowsi-
ness and fatigue are known to be deadly factors in
work and motor vehicle accidents. Every year, there
are more than one million motor vehicle accidents at-
tributable to lapses in driver awareness. The AMA re-
port calls for increased public education about the link
between sleep disorders, sleep deprivation and fatigue
and accidents. While drowsiness and fatigue affect all
drivers, they are particularly dangerous for truck driv-
ers and people who work nontraditional work sched-
ules. The AMA also called for tougher federal enforce-
ment of existing regulations on consecutive work
hours.
Regulation of Tattoo Artists and Facilities - The
"Rodman Resolution" (Resolution 506) - The AMA
called for regulation of tattoo artists and facilities. The
age-old activity of tattooing has come back into vogue
- particularly among youngsters. The AMA passed the
policy in response to concern over serious risks of bac-
terial or viral infection and allergic reactions in the
application of tattoos. The AMA wants to see states
regulate tattoo artists and tattoo facilities to ensure
adequate procedures to protect public health. In addi-
tion, the new AMA policy calls on physicians to re-
port any adverse reactions to tattoos in their patients
to the FDA Med Watch Program. Currently, tattooing
parlors are not uniformly regulated in this country.
Hard Liquor Advertising (Resolution 432) - In the
wake of a new hard liquor advertising campaign by
Seagram, the AMA voiced its strong exception by pass-
ing new policy calling for an immediate federal ban on
TV advertising of hard liquor products on commercial
television. This is the latest in a long list of established
AMA policies supporting federal legislation restrict-
ing advertising and promotion of alcoholic beverages.
The AMA's policies, in part, induced the liquor
industry's recently rescinded voluntary ban.
Assurance of the Publics Health Aboard Cruise
Ships (Resolution 429) - The AMA passed a policy
calling for the immediate development of standards
for providing medical care for passengers aboard cruise
ships entering or leaving the U.S. Currently, there is
no regulation or credentialing of cruise ship physicians
or on-board medical care. The AMA wants to see as-
surances that usual and customary public health and
medical practices are available on ships that are not of
U.S. registry.
Domestic Violence (Resolution 426) - Does man-
datory police reporting of domestic violence put vic-
tims in greater danger than allowing them to choose
to "press charges"? This is a concern of many victim
advocates. The AMA addressed the issue with a call
for the Association to actively evaluate the desirability
of a uniform national standard for persecuting domes-
tic violence cases and will work with victim advocacy
groups to assess the safety and effectiveness of cur-
rent mandatory reporting policies.
Expansion of AMA Policy on Female Genital
Mutilation (Resolution 513) - The AMA passed policy
Volume 93, Number 4 - September 1996
167
condemning the practice of female genital mutilation
(FGM). Defining the procedure as "a form of child
abuse," the AMA resolved to work with the U.S. Dept,
of Health and Human Services (HHS) to make FGM a
"reportable condition" which would require that
known incidence of the procedure would be reported
to state health departments and to the Centers for Dis-
ease Control and Prevention (GDC). In addition, the
AMA resolved to work with HHS to develop an edu-
cational program to provide culturally sensitive coun-
seling to help immigrant communities understand the
grave health risks associated with FGM, and to dis-
courage young girls and their families from having
the procedure performed.
Evidence-based Principles of Discharge and Dis-
charge Criteria (CSA Report 4) - The introduction of
drive-through deliveries made the country stand up
and take notice of changes in the medical marketplace
that have patients concerned that their insurance com-
panies may be putting financial considerations before
quality of care. The AMA passed a report that estab-
lishes an evidence-based criteria for determining when
patients can safely be discharged from the hospital.
The criteria puts patients and physicians back in the
driver's seat allowing them to make medical decisions
together without third-party interference.
AMA Challenges Health/Life Insurers and HMDs
to Divest of Tobacco Holdings (Board Report 49) - As
an extension of its 4/24 call for mutual funds to divest
of any tobacco holdings, the AMA called upon health
and life insurers and HMOs to do the same. The AMA's
call for tobacco-free investments will be an annual cam-
paign to provide health advocates with a method to
ensure their financial investments do not profit from
or support the tobacco industry.
Patient Protection Measure to Improve Disclo-
sure of Health Plan Limitations on Patient Choice of
Physicians (Resolution 115) - The AMA passed a reso-
lution directing the AMA in implementing its patient
protection legislative initiatives, to pursue the posi-
tion that every health plan should include a bold type,
front-page summary explicitly setting forth any plan
limitations in choice of primary care physician, or ac-
cess to specialists, in its marketing materials and writ-
ten policies provided to members. The summary will
also be required to contain easily understandable in-
formation on how physicians will be paid by the plan.
The AMA believes making this information available
to patients will make it easier for prospective health
plan members to evaluate the health care services avail-
able under the plan, and will lead to better informed
patients.
Inauguration of Daniel H. Johnson, Jr., M.D., as
AMA President - Daniel H. Johnson, Jr., M.D., be-
came the 151“' president of the AMA. Dr. Johnson, a
distinguished radiologist from Metairie, Louisiana, was
168
inaugurated in a ceremony before the AMA's House
of Delegates. In assuming the AMA's top office. Dr.
Johnson issued a strong call for patient choice - choice
of their physicians and choice of their health plans - as
essential to successful health system reform, and nec-
essary to the preservation of the patient-physician re-
lationship. Elsewhere in his Inaugural Address, he
praised the growing diversity of medicine - in race,
gender, age, specialty and practice setting.
Dr. Johnson was elected president by the House
of Delegates in June 1996 and served as president-elect
during the past year. He is clinical professor of radiol-
ogy and otolaryngology at Tulane University and was
co-founder of the American Society of Head and Neck
Radiology. He received his medical degree from the
University of Texas at Galveston.
Deaths from SIDS Drop
Deaths from Sudden Infant Death Syndrome
(SIDS) dropped 30% from 1993 to 1995, according to
the National Institute of Child Health and Human De-
velopment. Credit goes to the American Academy of
Pediatrics' "Back to Sleep" campaign, urging parents
to stop putting babies to sleep on their stomachs. -
Reprinted from The AHA Weekly NOTEBOOK, July 23,
1996, Vol. 3, Number 28.
New Service for Healthcare Professionals
The Excedrin Headache Resource Center™, an
educational outreach program sponsored by Bristol-
Myers Products, announces a new 800# service pro-
viding free informational resources to healthcare pro-
fessionals. Headache sufferers have had access to pa-
tient information through the toll-free number for
nearly one year. Now physicians, physician assistants,
nurses and other health professionals can call (800)
580-4455 to receive materials for themselves and their
patients. The service offers the following free of charge:
professional education materials, slide lecture kit on
treating headache, continuing medical education pro-
grams, patient education materials. Headache Relief
Update newsletter for patients, patient videotapes.
Wellness program - a guide to conduct headache semi-
nars in the workplace and Excedrin samples.
As First Year of MPH Program Ends,
Arkansans Describe Impressions,
Experiences, Plans
For the first time, Arkansans can receive a master
of public health (MPH) degree without leaving the
state. This summer, seven Arkansas students com-
pleted their first year of a new MPH program offered
by Tulane University through the UAMS Area Health
Education Centers (AHEC). Begun in the fall of 1995,
the two-year program will be completed in the sum-
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
mer of 1997. Designed to accommodate the work
schedules of practicing doctors, residents, nurses and
other health professionals, the classes meet alternat-
ing Fridays and Saturday afternoons on the UAMS
Campus.
Most of the Arkansas MPH students plan to be in
public health administration. Since demonstrated man-
agement skills are required for upper-level manage-
ment posts, the program (which includes specific fields
such as epidemiology, environmental health sciences
and health education) also focuses on broader issues,
such as leadership skills, communicating important
agency values to employees, dealing with changes in
the environment, and planning and mobilizing re-
sources to relate the operation of the agency to its larger
community role.
Student Profiles - Carol Cox, a Nursing Quality
Improvement Manager at the University Hospital, re-
located from Kansas to the University of Arkansas at
Little Rock (UALR) to complete a BS degree in health
education last year. Now enrolled in the MPH pro-
gram, Cox said she appreciates the opportunity to learn
from leaders in public health. She also said she likes the
more interactive learning experience that is possible m the
smaller classes. Cox plans to teach health education and
later hopes to develop a wellness center in Mountain
Home.
Angela Gulley-Smith, a 1995 graduate of the Uni-
versity of Central Arkansas in Conway, (UCA) also
holds a BS degree in health education. She enrolled in
the MPH program to broaden her opportunities in the
health education field and views the opportunity to
work with Tulane University "an honor." Smith said
she believes an urgent need exists to organize and imple-
ment education programs focused on violence, teen preg-
nancy, and drug addiction. Programs such as these are des-
perately needed in inner-cities because these areas are often
hard to reach. When Smith completes her degree, she
plans to work as a health educator in a hospital or the
community. Smith says the MPH program is excellent
and she "wouldn't trade it for anything."
Abdul Jazieh, M.D., a hematology/oncology fel-
low at UAMS, received his M.D. in Damascus, Syria.
He came to Arkansas to specialize at UAMS. Dr.
Jazieh's credentials also include a diplomat for the
American Board of Internal Medicine. He is board eli-
gible for medical hematology and oncology and a mem-
ber of the UAMS faculty. Dr. Jazieh enrolled in the
MPH program to help him develop cancer interven-
tion and education programs and expects the MPH
degree will enhance his ability to obtain grants for
health education programs. Dr. Jazieh believes Arkansas
has a great need for public health education and has a poten-
tial for many projects because the state has a big shortage of health
educators.
Viju Gopal, D.D.S., received her dental training
in her home country of India. A four-year resident of
Arkansas, Gopal enrolled in the MPH program to ac-
quire further post-graduate education toward her goal
of a position as a director of dental health in Jamaica.
Dr. Gopal said that in particular, she appreciates two
instructors from Arkansas who shared first-hand experience
with public health needs and access to public health informa-
tion in Arkansas. Gopal plans a preventive dental health
project with public school second graders for her
capstone project (a real "hands on" community health
project).
Indu Soora, a medical technologist who received
her formal training in India, said she enrolled in the
MPH program because she wanted to pursue a career
in the medical field. Soora sees a need to educate the
public about how and where to find medical resources
most suitable for their needs. She said that unedu-
cated and economically disadvantaged individuals
should be the focus of these efforts since basic medical
resources are often unavailable to them. Soora says
the MPH is an excellent program that ivill have positive
effects in the community.
Mike Anders, Education Diagnostics Manager at
Arkansas Children's Hospital (ACH), holds a BS de-
gree from Louisiana State University (LSU) and an
Associate degree in respiratory technology from
UAMS. He enrolled in the MPH program because it
presents the opportunity to work with Tulane Univer-
sity. Anders is excited about the curriculum and believes
the program is "excellent." He particularly appreciates the
professional treatment by the professors who are very distin-
guished in their fields. Career possibilities are wide open,
but Anders eventually hopes to pursue a doctorate in
public health.
Donald Simpson, a cytotechnologist at John L.
McLellan Memorial Veterans Administration (VA)
Medical Center moved to Little Rock from his home-
town of Ruston, Louisiana, to train in a health-related
field at UAMS. Simpson holds a BS in microbiology
from Louisiana Tech University (LTU) and a BS in cy-
totechnology from UAMS. Simpson said Arkansas has a
great need for public health education. He believes "health
educators need to realize that we are all in this to-
gether." For Simpson, the caring and professional fac-
ulty as well as the challenging course work make the
MPH program a positive and rewarding experience.
Once he completes the program, he hopes to use his
degree within health services at the VA Hospital.
Volume 93, Number 4 - September 1996
169
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AMS Newsmakers
Dr. Donald L.
Cohagan, a family
practitioner in Benton-
ville, recently received
the Spirit of Service
award from the Ar-
kansas Health Care
Access Foundation.
The award is given to
physicians who gener-
ously donate free
medical service to
needy persons in Ar-
kansas as qualified
through the Depart-
ment of Human Ser-
Donald L. Cohagan, M.D.
The Arkansas Chapter of the American College of
Radiology recently recognized Dr. George Regnier for
meritorious service to the clinical practice of radiology
in Arkansas. His colleagues in the radiology depart-
ment of Baxter County Regional Hospital delivered the
honorary plaque to him.
Dr. Dow B. Stough has written and recently pub-
lished a book titled, "Hair Replacement: Surgical and
Medical." The book contains surgical and medical in-
formation along with 759 illustrations and 13 color
plates. The book has 55 contributors from throughout
the world.
Dr. Jerry L. Thomas recently retired from his or-
thopedic clinic in Heber Springs. The clinic, which
opened in 1989, has served more than 5,000 patients.
Dr. Eugene Towbin
was recently honored
as he retired as chief
of staff of the John L.
McClellan Memorial
Veterans Hospital. He
has been associated
with the hospital for
40 years. Dr. Towbin
also was presented
with the "Distin-
guished Career Award"
sent by Jesse Brown,
secretary of Veterans
Affairs.
Eugene Towbin, M.D.
Dr. William Earle Jennings, who began practic-
ing medicine in Rogers in 1946, was recently honored
by Mayor John Sampler, the staff at St. Mary's Hospi-
tal, community leaders and his son (also a physician)
for fifty years of service to the hospital and commu-
nity. Although officially retired, the 77 year-old phy-
sician still sees patients at various nursing homes.
Dr. R. Jerry Mann, medical director of the Pri-
mary Care Center located at UAMS Medical Center,
was recently elected to serve on the board of directors
of the American Board of Family Practice. He will serve
a five-year term during which he will be responsible
for granting or revoking medical licenses in family practice.
The Physician's Recognition Award is awarded
each month to physicians who have completed accept-
able programs of continuing education. Recipients for
the month of July 1996 are: William L. Diacon, Bella
Vista; Stacey M. Johnson, Mountain Home; John
Wayne Joyce, Little Rock; Patricia Ann Knott,
Sherwood; James S. Magee, Little Rock; Laura Reeves
McLeane, North Little Rock; Virginia B. Melhorn, Little
Rock; Dac Tat Pham, Brinkley; Gregory F. Ricca,
Jonesboro; Joseph T. Wilson, Jonesboro; Michael W.
Young, Dardanelle.
In recognition of
Dr. Thomas H.
Hickey's services to
the health care com-
munity of Conway
County, J.T. Compton,
owner of Brookridge
Life Care and Rehabili-
tation Center, placed a
bronze plaque dedi-
cated to the physician
at the entrance of the
new facility. Dr.
Hickey is a general
practitioner in Morril-
ton. - Photograph taken
by Petit Jean Country Headlight photographer Dennis
Massingill.
(From left) Thomas H. Hickey, M.D.,
andJ. T. Compton
Volume 93, Number 4 - September 1996
171
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Profile
William L. Paul, M.D.
PROFESSIONAL INFORMATION
Specialty: Anesthesiology
Years in Practice: 21
Office: Little Rock
Medical School: University of Kentucky College of Medicine,
Lexington, 1972
Internship: University of South Florida, 1973
Residency: University of Florida, 1975
Honors! Awards: Physician's Recognition Award
PERSONAL INFORMATION
Family: Wife, Becky, and daughter, Wendy, 14 years old
Date/Place of Birth: February 14, 1946 in Hopkins County, Kentucky
Hobbies: fishing and hunting
THOUGHTS & OTHER INFORMATION
If I had a different job, I'd be: a fishing guide
Historical Figure I most identify with: Thomas Jefferson
Favorite junk food: peanuts
Most valued material possessions: my boat
The turning point of my life was when: people became more important than money or ideals
Favorite vacation spot: Florida
One goal I haven't achieved yet: to be the best physician I can be
One goal I am proud to have reached: being named Teacher of the Year
Favorite childhood memory: Sunday dinners at our farm with everyone in the family present and playing
When I was a child, I wanted to grow up to be: a scientist
One of my pet peeves: disorganization
First job: mowing lawns
Worst job: cleaning women's restrooms
My life philosophy: Is to attain peace in my life by understanding that we all have different agendas,
and that's okay.
If you are interested in appearing in either the New Member Profile or Member Profile, contact Tina Wade at the Arkansas Medical
Society at (501) 224-8967 or 1-800-542-1058.
Volume 93, Number 4 - September 1996
173
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174
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Special Article
Assessing Clinical
Medical Students
Jeanne K. Heard, M.D., Ph.D.* **
Ruth Allen, Ph.DA”^
Patrick W. Tank,
Gerald J. Cason, Ph.D.****
Mary CantrelP*’"’'’'
Richard P Wheeler, M.DA***""
Abstract
The clinical skills of sophomore medical students
at the University of Arkansas are being assessed
through the use of the Objective Structured Clinical
Examination (OSCE). This exam was developed in or-
der to better standardize the evaluation of practical
clinical skills. The exam uses standardized patients,
who are lay people trained to accurately and consis-
tently portray a patient encounter. Faculty members
at UAMS authored clinical cases for 20 patient encoun-
ters that test history taking, physical examination and
communication skills. Each student interacts with the
patient while being assessed in a standardized way,
and then is given educational feedback by a faculty
member. Students who do not pass the exam, undergo
a remediation program prior to entering the junior year.
Introduction
Improving the professional education of medical
students is an ongoing concern of the leaders of aca-
demic medical centers. During their first two years,
medical students in a traditional curriculum are as-
sessed primarily by recall of facts. Assessing a student's
clinical abilities is not a simple process for it requires
* Jeanne K. Heard, M.D., Ph.D., is Assistant Dean for Gradu-
ate Medical Education and Director of the Standardized Pa-
tient Program, College of Medicine, UAMS.
** Ruth Allen, Ph.D., is Associate Professor of the Office of
Educational Development, UAMS.
*** Patrick W. Tank, Ph.D., is Professor of Anatomy, College of
Medicine, UAMS.
**** Gerald J. Cason, Ph.D., is Associate Professor, Office of Edu-
cational Development, UAMS.
»»»»» Mary Cantrell is Assistant Director, Standardized Patient Pro-
gram College of Medicine, UAMS.
»»»»»» Richard P. Wheeler, M.D., is Associate Dean for Student and
Academic Affairs, College of Medicine, UAMS.
Skills of
explicit criteria for the systematic evaluation of clinical
performance. Because medical education has been fo-
cused on acquisition of facts, students' abilities to per-
form thorough history and physical examinations or
to develop competent interpersonal or communication
skills have been inadequately assessed by standard-
ized or objective methods.
The Objective Structured Clinical Examination
(OSCE) was developed by Hardin in Scotland in 1975
to better standardize the evaluation of clinical skills in
medical training. '* The OSCE is a practical examina-
tion where the student is asked to carry out a single
task or set of tasks in a series of stations. In one sta-
tion the student may be instructed to interview a pa-
tient about a headache. In another he or she may read
an x-ray or complete a written exercise relevant to the
preceding station. In another station the student may
examine a patient's abdomen. As the student
progresses through the series of stations, faculty mem-
bers observe and evaluate his or her performance by
completing a standard checklist.
Since 1975, the OSCE has become more widely
used in medical schools as it represents the first op-
portunity to directly and reliably assess clinical perfor-
mances in medical education. During the last decade,
a variety of multiple-station examinations have been
developed at various medical schools.'’’® These include
short station clinical encounters that focus on a single
skill or a particular set of skills or a longer station en-
counter that assesses the ability of the student to carry
out the complete episode of clinical performance for
the patient problem. The OSCE or short station ex-
amination is usually done early in clinical training to
assess the students' skills of physical examination and
taking a focused history. A more in-depth clinical skills
Volume 93, Number 4 - September 1996
175
Figure 1: Students read a short clinical scenario prior to entering the clinic room and interact-
ing with the SP.
examination is usually performed during the clinical
clerkships or at the beginning of the senior year to see
if the student is capable of carrying out a complete
encounter, applying the skills appropriate for the par-
ticular problem. It is a more in-depth test of clinical
competency, including patient management skills.
Thus, the use of practical clinical skills examinations
using patients is now more common, and in the near
future will be part of the licensing examinations for all
physicians in the United States.
In the past, students in the College of Medicine at
the University of Arkansas for Medical Sciences
(UAMS) have had few opportunities to practice this
type of clinical skills examination, and no means to
demonstrate their clinical competency by a practical
examination using live patients. Therefore, in 1991, at
the recommendation of the Dean of the College of
Medicine, the Curriculum Committee investigated
ways to develop this type of program at UAMS. Fac-
ulty visited medical schools at the University of New
Mexico and the University of Arizona in order to ob-
serve clinical skills examinations. In 1992, a subcom-
mittee of the Curriculum Committee recommended
that a feasibility study be conducted for developing an
Objective Structured Clinical Examination at UAMS.
Feasibility Study
In 1992 a general internist in the Department of
Medicine was appointed to direct the feasibility study;
twenty-five percent of her
non-clinical time was allocated for
the study. An OSCE subcommit-
tee of the Curriculum Committee
consisting of clinicians in pediat-
rics, obstetrics/gynecology, neu-
rology, surgery, family practice
and internal medicine, an educa-
tional specialist and an anatomist
was assembled. Their responsi-
bilities included determining the
administrative aspects of the clini-
cal skills exam, case writing and
developing a proposal to be pre-
sented to the College of Medicine
faculty.
Since the objective assess-
ment of clinical skills was a new
endeavor at UAMS, the subcom-
mittee decided to begin with the
objective assessment of clinical
skills at the sophomore level. The
subcommittee reasoned that once
the infrastructure was estab-
lished, a clinical competency ex-
amination for seniors could be
more easily developed. Twenty cases were developed
to test basic clinical skills of interviewing, communi-
cation and physical examination. Because these skills
have not been fully developed at the sophomore level,
the subcommittee believed that the OSCE should be
educational as well as evaluative. Sophomores could
be assessed on their skills with a standardized check-
list and then given feedback by faculty observers.
The examination was first given in 1993 to a small
group of students as a trial run so that logistical re-
quirements could be estimated and problems resolved.
The following year all 144 students took the examina-
tion, but were not required to pass it. In 1994 a pro-
posal to have an Objective Structured Clinical Exami-
nation for sophomore medical students was approved
by the College of Medicine faculty. Currently, students
must pass the examination to progress into the junior
year, and students who fail must complete remediation
before they progress.
Standardized Patient
Patients used in the OSCE are called standardized
patients. They are lay persons trained to accurately
and consistently portray a patient encounter. The con-
cept of standardized patients, also known as simu-
lated patients or SPs, was first developed 30 years ago
by Dr. Howard Barrows to solve an assessment prob-
lem in a clinical clerkship in neurology.’® He taught
lay people to simulate various neurological findings
176
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
for students on the service. The students not only
learned how to perform the mechanics of physical ex-
amination, but also were given valuable feedback by
the "patients" regarding their interviewing and inter-
personal skills. Since that time SPs have become widely
used and are now a very valuable tool in medical edu-
cation and assessment.
For approximately 20 years at UAMS, a form of SP
known as the teaching associate has been used to teach
and evaluate students' performance of the gynecologi-
cal examination. However, the use of SPs in other ar-
eas of the curriculum is limited. To support the needs
of an Objective Structured Clinical Examination, the
College of Medicine developed a more formal program
of SPs. SPs are hired based on their suitability for a
particular case for the OSCE. Recruitment involves
gathering demographic and medical history data from
a potential standardized patient, and interviewing the
person to determine his/her interest and ability. The
potential SP must also have an abbreviated physical
examination.
Once an SP's suitability has been determined, the
trainer discusses a particular case with the SP, helping
him or her relate to the situation and adapt as much
as possible from his or her own history. For instance,
at times the SP may use his/her own name, occupa-
tion or past medical history to incorporate in the case.
Prior to the OSCE, the SP "performs" the case with a
mock student in a dry run session while being ob-
served by the case author to ensure that the presenta-
tion is correct. Eor the OSCE, four SPs are trained for
each case. Each SP must present
the same scenario to each student.
Their dry run sessions are video-
taped so that their portrayal of the
case can be assessed to be repeat-
able and reliable.
Design of the OSCE
Medical students at UAMS
take a traditional curriculum of
basic science courses during the
first two years, followed by two
years of clinical training. Students
have three introductory clinical
courses during the first two years
that prepare them for the OSCE.
The Introduction to the Medical
Profession course, given during
the first semester of the freshman
year, provides the students with
opportunities to learn basic inter-
viewing techniques. During the
second semester of their sopho-
more year, students take Physical
Diagnosis in which they learn the basics of history
taking and physical examination techniques, and
Mechanisms of Disease which concentrates on the
pathophysiology of specific diseases.
The OSCE is given at the end of final examination
week in the sophomore year, and is comparable to a
biology or gross anatomy laboratory examination. In a
laboratory examination, students spend a specific
amount of time at a given station and respond to a set
of questions on which that station focuses. The OSCE
is given in a clinical setting, called a station, which
approximates an exam room. Within each station there
is a standardized patient, a specific set of items or tasks
to be performed, a faculty evaluator, and an SP evaluator.
The examination begins with the student reading
a short clinical scenario posted on the entrance to the
clinic room or station (Figure 1). This gives the stu-
dent specific instructions regarding the station. At the
sound of the buzzer, the student enters the station
and has 5 minutes to perform the specific task with
the standardized patient. The student is observed by
a faculty evaluator and an SP evaluator (Figure 2). After
5 minutes, the faculty evaluator stops the activity and
provides educational feedback to the student during
one and one-half minutes of interactive time (Figure
3). When the buzzer sounds again, the student enters
the hallway and proceeds to the next station to repeat
the process.
The OSCE consists of 16 clinical stations, 8 of which
assess physical examination skills (Figure 3), and 8 sta-
tions which assess history taking and interviewing
techniques (Figure 2), plus 4 rest stations. Eighteen
Figure 2: The student is observed by a faculty evaluator and an SP evaluator as he elicits a
history from the standardized patient who has presented with a headache.
Volume 93, Number 4 - September 1996
177
Figure 3: The faculty evaluator provides educational feedback to
the student on the correct method to perform the abdominal ex-
amination.
students can be tested at one time. The exam is given
in the Ambulatory Care Center on the weekend, us-
ing the exam rooms normally used for clinic patients
during the week. The rooms are prepared on Friday
night with the necessary equipment for each task and
the appropriate evaluation materials. In order to ex-
amine the entire class over a 12-hour period, 2 identi-
cal examinations are conducted simultaneously. Two
sets of student groups progress through parallel sets
of stations concurrently, and the rotations are repeated
4 times throughout the day. Four faculty evaluators
are trained for each case: two evaluate and provide
feedback in the morning examinations, and two evalu-
ate and give feedback during the afternoon examinations.
Cases used in the exam have been written by fac-
ulty in the College of Medicine and submitted to a
committee for review and selection. A case writing
blueprint exists to guide authors in their efforts. Cases
are usually based on a real patient or a combination of
real patients who have been seen by the case author.
After the case is written, it is submitted to the review
committee to ensure its appropriateness and validity.
Currently, UAMS has approximately 30 cases avail-
able in its "library." Each year several are added so
that a variety can be chosen for the examination. After
the case has been reviewed and approved, faculty and
SPs must be recruited and trained for each case.
Faculty Training
Because the objective assessment of clinical skills
in an examination format was new to faculty in the
College of Medicine, they also had to be trained in
how to* score the standardized checklists and give ef-
fective feedback. Faculty evaluators are usually clini-
cians from UAMS and the Area Health Education Cen-
ters. Several basic scientists and faculty from the Col-
lege of Nursing also participate.
Faculty members are trained in several steps to
assure consistency with regards to scoring. Initially,
they observe the case scenario presented by an SP with
a mock student being scored by the case author. The
standardized checklist is presented and discussed, and
questions are answered by the author. This is done so
that all clinicians will view the case in the same way
and score the students in the same way. Possible stu-
dent questions are also presented and answers offered
at this time. Then the case is presented to the clini-
cians again, but this time the mock student does not
perform well so that the faculty members have a chance
to score the event again and compare results with those
of the case author. Again, questions are answered so
that all faculty involved in the case score the student's
performance consistently and reliably.
Evaluation
The primary objective of the OSCE is to obtain
valid measures of each student's clinical performance
skills in medical history taking, physical examination
and communication. A second objective is the deliv-
ery of informative feedback by a faculty evaluator
following the evaluator's observation of the student-SP
encounter.
In preparation for the OSCE, specific evaluation
forms have been developed. The student score sheets
(standardized checklists) are designed specifically for
each case and provide a list of standard items to be
used by the faculty for evaluating student performance.
Each case's score sheet includes specific behaviors that
are general in nature and relate either to the focused
physical exam (e.g. hand washing, draping) or the
focused history exam ( e.g. onset, duration). Other
items relate directly to the case in question (e.g. per-
cussion of liver span for the abdominal pain case or
asking about high blood pressure on the case about
chest pain). All history cases include the same set of 9
items to evaluate the student's communication skills.
Present in the room during the exam are the stu-
dent, a faculty evaluator, and two SPs, one of whom
portrays the case to the student and another who evalu-
ates the performance along with the faculty educator.
There are three possible scores for each behavior; hon-
ors, pass or fail.
Several other evaluations are also obtained during
the exam. In addition to the faculty evaluating the students.
178 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
faculty also evaluate the exam itself, giving the OSCE
subcommittee valuable feedback for future OSCEs. The
faculty also evaluate the SP's portrayal of the case.
Therefore, any discrepancies between SPs portraying
the same case can be determined and corrected. The
SPs evaluate the overall OSCE process, which also
assists the subcommittee in improving future exami-
nations. In addition, the students evaluate the exam
process and the faculty feedback by judging the ap-
propriateness of each case and the type of feedback.
Faculty are rated by the students and receive scores
on their individual feedback performance that can be
used for self-improvement as well as in the promotion
and tenure process.
After the OSCE score sheets are processed by an
optical scanning machine, the data are analyzed and
reported by computer. Students are provided a set of
scores following the OSCE. The total physical exami-
nation score is an average of the 8 physical examina-
tion stations. For the 8 history cases, students receive
an overall history case score, a basic interviewing score,
and a communications score. Students who attain a
60% average score on all cases pass the OSCE.
Remediation
Students who do not meet the minimum 60% cu-
mulative score on the examination undergo a
remediation program during the weeks prior to their
junior year. Each case has a remediation plan written
and conducted by the case author. It must be success-
fully completed before the student can enter the jun-
ior year. Relevant information about student perfor-
mance from the OSCE is provided to freshman and
sophomore course directors so that they can make
changes in curriculum content and presentation format.
Conclusion
Developing and implementing an objective assess-
ment of clinical skills for medical students is a com-
plex and expensive process. Essential requirements for
success are thorough planning, strong support of the
administration and faculty, a diligent and interested
coordinating committee, and well trained standard-
ized patients. Results of an OSCE can provide assur-
ance that students are gaining the clinical skills neces-
sary to provide quality patient care. Results of an OSCE
can also provide an evaluation of a current curriculum
and an impetus for constant improvement and revision.
In the future the National Board of Medical Exam-
iners (NBME) will require students to pass an exami-
nation to be given in the first part of their senior year
as part of the United States Medical Licensing Exam
(USMLE). This exam, the Clinical Practice Exam or
CPX, is similar to the OSCE given to sophomore stu-
dents, but requires a greater degree of proficiency in
clinical skills by the senior student. Currently, UAMS
is working with the NBME to offer a prototype of this
more advanced examination to senior students at
UAMS, so that they will be better prepared to take
and pass the USMLE successfully. Evaluations such
as these are just another way medical schools can en-
sure that graduating students and future physicians
receive the highest quality of medical training in the
care of patients.
References
1. Swanson, AG. Educating medical students: assessing
change in medical education- the road to implementation.
Acad Med 1993; 68(suppl 6): S23-S27.
2. Stillman PL, Swanson DB. Ensuring the clinical compe-
tence of medical school graduates through standardized pa-
tients. Arch Inter Med 1987;147: 1049-1062.
3. Fabrey LJ, Case SM, Andrew BJ. Assessment of clinical
skills in US medical schools. J Med Ed 1984; 59: 957-959.
4. Harden RM. What is an osce? Medical Teacher 1988; 10: 19-22.
5. NuViet V, Barrows HS, Marcy ML, Berhulst SJ, Coliver
JA, Travis T. Six years of comprehensive, clinical,
performance-based assessment using standardized patients
at the Southern Illinois University School of Medicine. Acad
Medl992;67: 42-50.
6. Stillman PL, Regan MB, Swanson DB. A diagnostic
fourth-year performance assessment. Arch Inter Med 1987;
147:1981-1985.
7. Stillman PL, Regan MB, Swanson DB, Case S, McCahan
J, Feinblatt J, Smith SR, Willms J, Nelson DV. An assessment
of the clinical skills of four year students at four New En-
gland medical schools. Acad Med 1990; 65: 320-326.
8. Stillman PL, Regan MB, Philbin MB, Haley H. Results of
a survey on the use of standardized patients to teach and
evaluate clinical skills. Acad Med 1990; 65:288-292.
9. NuViet V, Barrows HS. Use of standardized patients in
clinical assessments; recent developments and measurement
findings. Educational Researcher 1994; 23:23-30.
10. Barrows HS, Abrahamson S. The programmed patient; a
technique for appraising student performance in clinical neu-
rology. J Med Ed 1964; 39:802-805.
Acknowledgments: The authors acknowledge the strong support
of Dr. I. Dodd Wdson, Dean of the College of Medicine at UAMS
and the OSCE subcommittee members- Drs. Michael Chesser, John
Eidt, Thomas Kramer, Jess Nichols, Gerry San Pedro, Steve Strode
and Mr. Skip Dahlgren; Mrs. Ann Norwood for preparation of the
manuscript and assistance with administering the OSCE; and the
editorial assistance of Ms. Shellie Newell.
Volume 93, Number 4 - September 1996
179
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Special Article
Breastfeeding in Arkansas: Trends in the
Northeast Region and Physician Self
Assessment Quiz
Mark Albey, M.D.”^
Sherry Rickard, R.N., I.B.C.L.C.’^* ** ***
Warren Skaug,
Introduction
Prevalence of breastfeeding in the United States
has gone through several changes over the past twenty-
five years. From a nadir in 1970 of 24.9% to a peak in
1982 of 61.9%, the rate had decreased by 1989 of 52.2%.’
Of those mothers who initiate breastfeeding, nearly
80% have discontinued by six months.^
There are a number of known influences on the
choice to begin and to continue breastfeeding. Being
young and poor are important factors working against
breastfeeding. But nursing mothers have cited poor or
conflicting advice from medical personnel as a signifi-
cant detriment to successful breastfeeding.^
Physicians universally advocate breastfeeding, but
often find themselves ill equipped to handle specific
problems or questions. There is in fact a dearth of prac-
tical breastfeeding information in current medical lit-
erature. The field has become the domain of the lacta-
tion specialist, with its own specialty publications."'
The purpose of this review is two-fold: We have
reviewed the St. Bernard's Regional Medical Center
breastfeeding experience for the past four years, to al-
low comparison with other obstetric services through-
out the state, and we have offered a "breastfeeding
I.Q." quiz for physicians, with answers provided.
Methods and Findings
Data were collected at St. Bernard's Regional Medi-
cal Center (SBRMC), a 325-bed regional referral cen-
ter, beginning in 1991. At this time, a Certified Lacta-
tion Consultant was employed at SBRMC. Through
use of patient surveys and telephone follow-up, the
number of patients who were breastfeeding at the time
of discharge, and at subsequent intervals, was deter-
* Mark Albey, M.D., a recent graduate of the AHEC-NE Family
Practice Residency Program, is now in private practice in Benton.
** Sherry Rickard, R.N., I.B.C.L.C., heads the department of
Breastfeeding Resource Services at St. Bernard's Regional
Medical Center in Jonesboro.
*** Warren Skaug, M.D., is a pediatrician in private practice in
Jonesboro and a faculty member of AHEC-Northeast.
Volume 93, Number 4 - September 1996
mined. An approximate average of 1,100 infants were
delivered each year during this study period. In 1991,
twenty-two percent of mothers were breastfeeding
upon discharge. By 1994, this number had risen to
48%. The only controlled variable that changed over
this time period was the employment of a full time
Certified Lactation Consultant.
Data from 1993 were analyzed to see how many
mothers who were breastfeeding at the time of dis-
charge were still breastfeeding six months later. Of
100 women who were breastfeeding at discharge, only
20 were still breastfeeding six months later. There were
no statistical differences in the educational levels or
other social variables in these two groups. Of the 80
who stopped breastfeeding, 75 discontinued because
of either decreased or perceived decreased milk sup-
ply. All but five of these mothers had supplemented
their breastfeeding with formula prior to 3 weeks of
age. The remainder discontinued breastfeeding at the
advice of their physician because of jaundice.
Of the 20 patients who continued breastfeeding
their infants six months after discharge, one had em-
ployed early supplemental feeds. This group was ques-
tioned regarding the quality of advice from their phy-
sicians and their physicians' nurses. Only one of these
20 patients stated that she received what was perceived
to be "good advice" from medical personnel. The most
helpful support systems mentioned were the Certified
Lactation Consultant and the LaLeche Organization.
In addition to the survey results, several other
observations over this four-year period are notable.
Newborns with ankyloglossia were identified and fol-
lowed. There were a total of 13 infants born with "func-
tionally significant" ankyloglossia to breastfeeding
mothers. These were defined by the mother complain-
ing of very sore nipples at less than 12 hours after
delivery, with an infant who was unable to extend the
tongue over the lower gum line. Six of these infants
underwent frenulectomy in the nursery, performed
by their pediatrician, their family physician, or an ENT
physician. Three of the 13 infants underwent
181
frenulectomy one to four weeks later because of poor
weight gain or cracked nipples. There were no com-
plications reported. All of these infants were able to
breastfeed successfully and were still breastfeeding nine
months later. Of the four patients who did not un-
dergo frenulectomy, two were able to breastfeed suc-
cessfully after six weeks of intensive instruction from
the Certified Lactation Consultant. One infant discon-
tinued breastfeeding because of poor weight gain and
another because of severe soreness and cracked nipples
in the mother.
Ten women who had received breast augmenta-
tion and three who had undergone breast reduction
were also followed. Of those with augmentation, none
were able to breastfeed successfully. None of the
women with breast reduction were able to breastfeed
exclusively. Some partial success was obtained with
supplemental devices.
No quantitative data were collected on mothers
who smoked, but it was our observation that most
women who smoked decided not to breastfeed. Of
those women who did smoke and chose to breastfeed,
smoking more than one and one half packs per day
was associated with an inadequate milk supply, based
upon feeding behavior and poor weight gain, whereas,
consumption of less than one pack per day allowed
for successful breastfeeding in several cases.
Discussion
Several observations merit further discussion. The
percentage of breastfeeding mothers at discharge from
St. Bernard's Regional Medical Center in 1991, was
less than one-half of published national norms. By 1994,
this percentage had more than doubled and now ap-
proximates the national average. The increase is in
direct relation to the full time employment of a certi-
fied lactation consultant and a focused breastfeeding
education program at our hospital. This phenomenon
illustrates a meaningful role for patient education and
support in the decision to Breastfeeding.
The rate of discontinuance of breastfeeding at six
months is similar in our experience as in published
national statistics.^- ^ There are many possible reasons,
but one prominent correlate with discontinuance was
early (less than 3 weeks) supplemental feedings. These
findings have clear implications for supplementation
policy in delivering hospitals.
Survey results indicated that the quality of physi-
cian advice was perceived as poor and that the most
valued support sources were the Certified Lactation
Consultant (CLC) and the LaLeche League. This area
may represent a "weak link" in many physicians' pa-
rental counseling skills and a team approach to
breastfeeding support is suggested.
A number of Arkansas communities currently have
Certified Lactation Consultants (CLC) whose training
includes at least 2,500 hours of breastfeeding counsel-
ing, a two- to five-year formalized and self-directed
training program, passage of a board exam and 30 hours
182
of annual continuing education in their speciatly.*
CLC's are capable of handling complex and difficult
breastfeeding problems.
Many hospitals and medical practices in the state
also employ breastfeeding educators. Though their
training is less extensive (training programs vary), these
individuals are capable of teaching prenatal
breastfeeding classes and assisting with normal
breastfeeding instruction in primary care settings.
In addition to these, the Arkansas Department of
Health, Office of Breastfeeding Services has enhanced
the breastfeeding educational capability of the county
health units throughout Arkansas.
Ankyloglossia and the therapeutic role of
frenulectomy represent a controversial issue. The four-
teenth edition of Nelson's Textbook of Pediatrics states
that a short lingual frenulum is of "no known func-
tional significance."’ However, several recent articles
support the role of ankyloglossia as a detriment to
successful breastfeeding and the benefit of tongue-clip-
ping in this setting.’®' Our own four-year experi-
ence with breastfeeding newborns suggests there may
indeed be a niche for this procedure in clinical medicine.
Nursing mothers who have undergone breast aug-
mentation or reduction were encountered regularly,
reflecting the prevalence of these procedures in our
society. Our results are reflective of published papers
and demonstrate an encouraging success rate for moth-
ers with augmentation, though complete success at
breast is substantially poorer in those with breast re-
duction.’® Both groups require the familiarity of the
clinician with their specific needs.
Smoking history is an important component in
breastfeeding initiation and success rate. Our experi-
ence suggests that barring cessation of smoking, less
is definitely better, and mothers unwilling to quit may
still successfully breastfeed. Several authorities sug-
gest that smoking mothers be encouraged to breastfeed
and that the advantages to the infant outweigh the
disadvantages.’'’- ’®-
The multitude of advantages of breastfeeding to
an infant's growth, development and general health
are well documented and are beyond the scope of this
review. But, for the physician, communication of prac-
tical current knowledge in breastfeeding method and
technical problem solving, so critical to the success of
breastfeeding mothers, has not kept pace with other
preventive health care issues. We would suggest that
this is best done through a team approach to include,
where possible, a trained specialist in this arena. Addi-
tionally, it is important for physicians to personally
stay current with this evolving field. Both efforts are
important to maximize breastfeeding success in our
communities.
Recommended Resources
* Auerback K, Riorden J. Breastfeeding and Human
Lactation. Boston: Jones and Bartlett (1993).
* Laurence RA. Breast-feeding: A Guide for the Medi-
cal Profession. St. Louis: CV Mosby Co. (1994).
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
BREASTFEEDING I.Q. QUIZ
(adapted from C.A. Lewinski)^
This quiz is intended as a brief learning exercise and self assessment tool for physicians and other health
professionals who deal with breastfeeding mothers. The questions reflect a number of frequently encountered
breastfeeding situations. No scorecard will be kept!
1. Mothers should be instructed to start out nursing 3-5 minutes on each breast TRUE
to prevent sore nipples. FALSE
2. The let-down response almost always occurs within the first minute of TRUE
breastfeeding. FALSE
3. Giving formula between breastfeeds during the first three weeks produces nipple TRUE
confusion and interferes with the mother's milk supply. FALSE
4. Sending home a discharge packet of formula could undermine the success of a TRUE
breastfeeding mother. FALSE
5. Glucose water helps decrease the physiologic jaundice often seen in TRUE
breastfed babies. FALSE
6. A 3-1/2 day old term newborn with a bilirubin of 15 mg% needs to discontinue TRUE
breastfeeding for at least 24 hours. FALSE
7. Newborns should be allowed unlimited access for breast feeding from the TRUE
moment of birth. FALSE
8. Nipple shields are an effective routine treatment for sore nipples. TRUE
FALSE
9. Mothers with inverted nipples cannot breast feed. TRUE
FALSE
10. If a breastfeeding baby has thrush, the mother's nipples must also be treated TRUE
after each nursing. FALSE
11. When a mother has non-purulent mastitis, breastfeeding must be discontinued TRUE
on the affected side. FALSE
12. After the first month of age, it is not unusual for an exclusively breast fed baby TRUE
to go 4 to 5 days without having a stool. FALSE
ANSWERS ON NEXT PAGE
References
1. Emery JM, Scholey S, Taylor EM. Decline in Breast Feeding.
Archives of Diseases of Children. 65 (4 Spec. No.):369-372 (1990).
2. Hoekelman RA. A Pediatrician's View: Highs and Lows
in Breastfeeding Rates. Pediatric Annals. 21: 615-619 (1990).
3. Bruce NG, Khan Z, Olsen NDL. Hospital and Other In-
fluences on the Uptake and Maintenance of Breast Feeding:
the Development of Infant Feeding Policy in a District. Pub-
lic Health. 105: 357-368 (1991).
4. Journal of Human Lactation (Official Journal of the Inter-
national Lactation Consultant Association) New York: Hu-
man Sciences Press, Inc.
5. Lewinski CA. Nurses' Knowledge of Breastfeeding in a
Clinical Setting. Journal of Human Lactation. 8 (3): 143-148 (1992).
6. Iker CE, Mogan J. Supplementation of Breastfed Infants:
Does Continuing Education for Nurses Make a Difference?
Journal of Human Lactation. 8(3): 131-136 (1992).
7. Loughlin HH, Clapp-Channing NE, Gehlbach SH, Pol-
lard JC, McCutchen TM. Early Termination of Breast-feed-
ing: Identifying Those at Risk. Pediatrics. 75 (3): 508-513 (1985).
8. International Board of Lactation Consultants Examiners,
Inc. P.O. Box 2348, Falls Church VA 22042.
9. Behrman RE, Vaughan VC: Nelson Textbook of Pediatrics.
Fourteenth Edition. Philadelphia: WB Saunders Co. (1992).
10. Berg KL. Tongue-tie (Ankyloglossia) and Breastfeeding:
continued on next page
Volume 93, Number 4 - September 1996
183
BREASTFEEDING I.Q. QUIZ - ANSWERS
(Based on jnaterials in Recoinmended Resources)
1. FALSE. Lactation studies show that the most common causes for nipple soreness are poor latch-on and
incorrect positioning, and not the duration of feeding.
2. FALSE. The let-down response (milk ejection reflex) requires a variable amount of time, usually from 1-3
minutes. Mothers' expectations must be addressed accordingly.
3. TRUE. "Complementary feeds" decrease time on the breast and therefore reduce prolactin levels and milk
production. Nipple confusion is a documented phenomenon. Ultrasound studies demonstrate that a chew-
ing motion predominates on the bottle vs. a suckling movement on the breast.
4. TRUE. Early (first three weeks) supplemental formula feedings have been shown to decrease success of
breast feedings and the practice has no evident value. The availability to nursing mothers of free formula
through hospitals or doctor's offices is an endorsement of its use.
5. FALSE. Glucose water increases urinary output. Physiologic excretion of bilirubin is through the gastrointes-
tinal tract.
6. FALSE. Physiologic jaundice is not modified by changing to the bottle. Increasing breast feeds to a minimum
of eight per 24 hour period and assuring proper technique are the appropriate solutions. "Breast milk jaun-
dice" is relatively rare and occurs after the first week of life.
7. TRUE. Frequent feeding, including nighttime feeds increase prolactin levels and milk production. Healthy
infants are alert and ready to feed from the moment of birth and with proper body heat precautions, they
may be allowed to feed immediately post partum.
8. FALSE. Nipple shields have been shown to decrease the milk supply 40 - 70% and to cause nipple confusion
in the infant.
9. FALSE. Inverted nipples noted during the last trimester of pregnancy can usually be corrected with breast
shells worn 8 hours per day prior to delivery, allowing successful breastfeeding.
10. TRUE. Maternal monilia can cause significant nipple soreness and is almost always present in the setting of
a nursing infant with thrush.
11. FALSE. Mastitis is usually caused by a plugged duct that has gone unresolved. Breastfeeding in this situation
is of no risk to the baby and helps to resolve the problem. The penicillin and cephalosporin antibiotics
commonly used to treat mastitis do not present a problem to the nursing infant.
12. TRUE. The typical stool pattern for a breast fed baby, once the maternal milk supply is in, includes a
minimum of four stools per day for the first 2-1/2 to 3 weeks. Bowel movements subsequently slow down
dramatically and are variable - from once daily to as infrequent as every 4 to 5 days. If the infant appears
healthy and the stools are soft, infrequent stools at this age are not abnormal.
References cont.
A Review. Journal of Human Lactation. 6(3): 109-112 (1990).
11. Fleiss PM, Burger M, Ramkumar H, Carrington P. Anky-
loglossia: A Cause of Breastfeeding Problems? Journal of
Human Lactation. 6(3): 128-129 (1990).
12. Notestine GE. The Importance of the identification of
Ankyloglossia (Short Lingual Frenulum) as a Cause of
Breastfeeding Problems. Journal of Human Lactation. 6(3):
113-115 (1990).
13. Widdice L. The Effects of Breast Reduction and Breast
Augmentation Surgery on Lactation: An Annotated Bibliog-
raphy. Journal of Human Lactation. 9(3): 161-171 (1993).
14. Newman J. Drugs in Breastmilk (Letter). Pediatrics 86:
148 (1990).
15. Anderson P. Drug Use During Breastfeeding. Clinical
Pharmacology 10: 594-624 (1991).
16. Chen Y. Synergistic Effect of Passive Smoking and Artifi-
cial Feeding on Hospitalization for Respiratory Illness in Early
Childhood. Chest. 95(5): 1004-1007 (1989).
184
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Special Article
Breastfeeding in Arkansas: The Role of the
Arkansas Department of Health
Malinda O. Webb, M.D.’^
Susan M. Ellerbee, Ph.D., R.N.C.’^’^
In 1978, the Surgeon General's report on Health
Promotion and Disease Prevention identified
breastfeeding as a national health objective.’ By the
end of the 1980's, the incidence of breastfeeding was
actually declining among all women with the lowest
rates in the lower socioeconomic groups. In Arkansas,
only 35 percent of delivering women initiated
breastfeeding in 1989. A token 8.2 percent continued
for six months.^ Recognizing the trend, the Surgeon
General established new goals in 1990. These new tar-
gets were for 75 percent of women to initiate
breastfeeding and for 50 percent to continue for 5 or 6
months by the year 2000.-^ Goals set by Arkansas in
1990 reflect the lower breastfeeding rates in the state.
By the year 2000, Arkansas plans to have 50 percent of
delivering mothers breastfeeding at hospital discharge
and 20 percent continuing for 5 or 6 months.''
The Surgeon General convened a conference to
examine the barriers to breastfeeding in 1984. The con-
ference formulated ways to overcome the barriers, par-
ticularly among minorities, the young and uneducated
families. Barriers identified by the conference included
the lack of adequate knowledge among health care
providers and their patients and the availability of free
or reduced cost formula through programs such as
WIG.® New moneys were authorized to overcome these
barriers. The WIG Reauthorization Act of 1989 estab-
lished a number of requirements for the promotion of
breastfeeding to those families who qualify. The Ma-
ternal Child Health Bureau of the Department of Health
and Human Services (DHHS) made available other
funds for grants of Special Regional and National Sig-
nificance (SPRANS). Dr. Linda Black, a former Arkan-
sas Department of Health pediatrician, created the
* Malinda Webb, M.D., of UAMS and the Arkansas Dept, of
Health Office of Breastfeeding Services, is an Assistant Profes-
sor in the Department of Pediatrics and serves as the Medical
Consultant to the Office of Breastfeeding Services (OBS).
** Susan M. Ellerbee is the Administrator of OBS and Breastfeeding
Promotion Coordinator for Arkansas WIC Program.
Office of Breastfeeding Services (OBS). Her vision was
to utilize the talents of the University of Arkansas for
Medical Science (UAMS), Arkansas Children's Hospi-
tal and the ADH to promote and support breastfeeding
in Arkansas. She was awarded a SPRANS grant. Ad-
ditional funding was later provided by Arkansas WIC.
She assembled a group of physicians, nurses, and
nutritionists from these institutions, and was able to
get intensive training regarding breastfeeding and lac-
tation for this team.
Since 1990, funding has changed as has the direc-
tor and staff. WIC now provides 80% of the funding
with the remainder coming from other federal grants.
The staff currently consists of a nutritionist, a
maternal-child health nurse, a social worker and a peer
counselor all of whom are Certified Lactation Consult-
ants. The administrator holds a doctorate in nursing.
A pediatrician serves as medical consultant. The cur-
rent mission of the Office of Breastfeeding Services is
threefold: To promote the practice of breastfeeding, to
educate health care providers about all aspects of lac-
tation, and to support the family that chooses to
breastfeed.
Promotion of breastfeeding
The target of promotional efforts at OBS is the WIC
client. The office helps the WIC program follow the
mandates established in the WIC Reauthorization Act
of 1989. In 1996, $21 per pregnant or breastfeeding
WIC client is directed to the promotion of
breastfeeding. OBS maintains a stock of pamphlets
specifically targeted to these clients. These pamphlets
address a number of concerns that a woman or her
family may have such as the myth that she will have
to avoid many foods, and that the father will not be as
involved. In addition, mother and baby T-shirts are
given out as incentives.
A program that has proven successful in many
areas of the country is peer counseling.'’'^ ADH has 12
peer counselors serving 21 counties (Fig. 1). They at-
Volume 93, Number 4 - September 1996
185
tend maternity clinics and are available to talk to moth-
ers regarding their infant feeding choices. A peer is
often less threatening and provides a role model for
these women. Many counselors are allowed to bring
their infants to clinic.
Workshops teaching the promotion of
breastfeeding have been held in all areas of the state.
Local health units, physicians' offices and hospitals
have participated. All members of the health care team
whether nurse, nutritionist, receptionist or clerk are
important in this effort. Future plans include the de-
velopment of more workshops as well as training lo-
cal leaders to continue these promotional efforts.
Education
Knowledgeable health care providers at every level
are important to the promotion and success of
breastfeeding. The Arkansas team was fortunate to be
part of a field trial of a lactation curriculum developed
by Wellstart International.® Portions of that curricu-
lum were used to develop a unique curriculum that is
taught to first year pediatric, obstetricsXgynecology,
and family medicine residents at UAMS Medical Cen-
ter. Clinical experience is enhanced by a half-day visit
to the Office of Breastfeeding Services. Medical stu-
dents are also exposed to these lectures and may have
the opportunity of seeing patients in the Lactation
Clinic at Arkansas Children's Hospital. Nursing and
nutrition students also rotate through OBS for clinical
186
experience and to learn of the
services that it provides.
The Office of Breastfeeding
Services has provided numer-
ous workshops to health de-
partment clinics and hospitals
around the state and will con-
tinue this as a major function.
A quarterly newsletter updates
health care providers on re-
search related to breastfeeding,
upcoming educational activi-
ties, and resources around the
state. In February 1995, the Ar-
kansas Department of Health
and UAMS sponsored a re-
gional seminar on breastfeeding.
The three featured speakers
were prestigious physicians and
researchers from the U. S. and
Canada. Future seminars are
being planned with the hope of
more participation by state phy-
sicians.
An intensive, week-long
course is offered twice a year to
prepare health care providers
for certification as lactation consultants. To date, 65
individuals have completed the course. Of these, 13
have obtained certification through the International
Board of Certified Lactation Consultants. Participants
for this workshop are selected so most geographical
areas of the state are represented.
Support of the breastfeeding family
The Office of Breastfeeding Services maintains a
state-wide help line (1-800-445-6175) daily with evening
and weekend coverage on a limited basis. (In Pulaski
County, call 663-0892.) This service is available for fami-
lies as well as health care providers. A clinic is held 2
days a week. Referrals come from many of the family
practitioners, pediatricians and obstetricians in the
central Arkansas area. Currently no fees are charged.
Clinic visits usually involve complex breastfeeding
problems, but prenatal patients with breast abnormali-
ties or who simply desire more information are also seen.
A pump loan program is available for WIC clients.
They may obtain a piston-type electric pump if they
are trying to establish a milk supply for a sick or pre-
mature infant. A simple, portable electric pump is avail-
able for those clients returning to work or school. Lo-
cal health units obtain manual pumps and other
breastfeeding supplies through the OBS. A lending
library of videos and books related to breastfeeding
and parenting is also available.
As the public awareness of the importance of
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
breastfeeding increases, health care providers should
take heed. Since 1990, the initiation of breastfeeding
in Arkansas has increased from 37.6% to 44.8% in 1994. ’
The overall breastfeeding rate for WIC clients is 9.22%,
up from 3.44% in 1990. ’“Increasing the incidence and
duration of breastfeeding in Arkansas is a goal for all
its citizens. The Arkansas Department of Health's Of-
fice of Breastfeeding Services is working with you to
keep your hometown healthy by promoting and sup-
porting breastfeeding as well as helping to educate
health care providers to do the same.
References
1. Promoting Health/ Preventing Disease: Objectives for the
Nation. Washington, DC; US Department of Health and
Human Services, 1980.
2. Ross Mothers Survey. Columbus, OH, Ross Laboratories, 1995.
3. Healthy People 2000. Rockville, MD: US Department of
Health and Human Services; 1990.
4. Healthy Arkansans 2000: Arkansas Health Promotion and
Disease Prevention Objectives. Little Rock, AR, Arkansas
Department of Health, 1991.
5. Report of the Surgeon General's Workshop on
Breastfeeding and Human Lactation. Washington, DC: US
Department of Health and Human Services; 1984. Publica-
tion HAS-D-MC 84-2.
6. Spisak S, and Gross SS: Second Follow-up Report: The
Surgeon General's Workshop on Breastfeeding And Human
Lactation. Washington, DC: National Center for Education
in Maternal and Child Health, 1991.
7. Kistin N, Abramson R, Dublin P: Effect of peer counse-
lors on breastfeeding initiation, exclusivity, and duration
among low-income urban women. Journal of Human Lacta-
tion 1994;10: 1 1-15.
8. Woodward-Lopez G, Creer AE (eds): Lactation Manage-
ment Curriculum: A Eaculty Guide for Schools of Medicine,
Nursing, and Nutrition. San Diego, CA, Wellstart Interna-
tional and University of California, San Diego, 1994.
9. Ross Mothers Survey. Columbus, OH, Ross Laboratories, 1995.
10. Women, Infants and Children Supplemental Food (WIC)
Program, Arkansas Department of Health, 1995.
PHYSICIAN RESIDENT ALERT:
IF YOU COULD USE OVER $25^00 A YEAR-
ANSWER THIS AD.
The U.S. Army’s Financial Assistance
Program (FAP) is offering a subsidy of over
$25,000 a year for training in certain medical
specialities.
Here’s how it breaks down - an annual
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ment of approved educational expenses.
You will be part of a unique health care
team where you will find many opportunities
to continue your medical education, work at
state-of-the-art facilities, and receive outstand-
ing benefits.
So, if you are a physician resident who
could use over $25,000 a year, contact an
Army Medical Counselor immediately.
800-USA-ARMY
ARMY MEDICIHE. BE ALL YOU CAN BE.®
Volume 93, Number 4 - September 1996
187
Western W'ildlife
As f^asirniers moved ttVsi. pioneers ^^^\LLc
foiind.animuU as e*otir as (he land^j{^
buffalo, prairie dogs, bean, beaverf/bighorrr M
sheep, rougars. wolves and raiiiesrfMs.
jt The eagle becairy a national ssinbol. <
^lOOMhuJ
:hank
M made it
ra like to sw
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Thanks agoiu
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<^Pentioi
knoMledi
TYhere n>er
oeople to.
Jhor more
information
on how
you can help,
call AHCAF at
(501) 221-3033
r (800) 950-8233
Arkansas Health Care
Access Fwindation, Die.
W those physicians who volunteer ^
’ through the Arkansas Health
Care A ccess Foundation, \
Thank You!
As you can see from a sampling of
letters we have received, your
L involvement in our program is J
Al appreciated and in many
life-saving, ■•yjl//llllll
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Volume 93, Number 4 - September 1996
189
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Cardiology Commentary and Update
James R. Thrasher, M.D.*
J. David Talley, M.D.**
SYNCOPE AND AORTIC VALVE STENOSIS: CLUES TO DIAGNOSIS
AND PATHOPHYSIOLOGY
Angina pectoris, syncope, and congestive heart
failure are the hallmark symptoms of aortic stenosis.
Syncope due to aortic stenosis was first described in
1706 by Cowper in a patient who "complained of great
faintness, and now and then pain about the heart..."’
In this issue of CCU, we review the clues to diagnosis
and pathophysiology of syncope due to aortic stenosis.
Patient Report
A 68 year-old male "passed out" while at rest in
his fishing boat (Table 1, Complete Problem List).^This
was his first episode of loss of consciousness. He was
at rest without prior exertion. He was alone and there
were no witnesses to the event. The incident happened
suddenly, and he was unsure of the duration of the
episode. While there was no loss of bowel or bladder
control, he did sustain a small laceration to the left
eyebrow. He did not drink alcohol or use illicit drugs.
He had a history of a "heart murmur" prior to his
discharge from the military service in 1948. This mur-
mur had not been evaluated. There was no history of
prior myocardial infarction, rheumatic heart disease,
or stroke.
The blood pressure was 133/85 mmHg. The am-
plitude of the peripheral pulses was diminished. The
chest was normal. The first heart sound was normal,
the second heart sound was diminished. There was a
grade II/VI holosystolic murmur heard at the base of
the heart which extended into the second heart sound.
A grade 1/VI diastolic murmur was heard at the left
lower sternal border.
The electrocardiogram showed a sinus rhythm, rate
* James R. Thrasher, M.D., is a Resident in the Department of
Internal Medicine.
** J. David Talley, M.D., is Professor of Internal Medicine and
Director of the Division of Cardiology, Department of Internal
Medicine, UAMS Medical Center.
of 71 beats per minute, left atrial abnormality, and a
left anterior fascicular block. Severe calcification and
stenosis of the aortic valve were seen on the transtho-
racic echocardiography.
Cardiac catheterization showed a 100 mmHg
peak-to-peak gradient across the aortic value, normal
left ventricular systolic function, and an
angiographically significant stenosis in the right coro-
nary artery. He underwent uneventful aortic value
replacement with a #23 St. Jude aortic valve (St. Jude
Medical Inc., St. Paul, MN) and single reverse saphe-
nous vein bypass graft was placed to the distal right
coronary artery. Since open heart surgery, there have
been several recurrent episodes of syncope, similar to
the initial event. Ambulatory monitoring and an event
recorder did not show an arrhythmia. An electrophysi-
ological study revealed only inducible atrial flutter and
a beta-adenegeric blocking agent was prescribed. A
complete neurological evaluation was normal. The eti-
ology of the syncopal episodes remains undefined. The
patient continues to fish.
The Hemodynamics of Aortic Stenosis
Aortic stenosis decreases blood flow across the
aortic valve during ventricular systole. Symptomatic
aortic stenosis occurs when the valve size is severely
reduced, generally at an orifice size of 1.0 cm^or less
(normal size > 2 cm^) which is accompanied by an in-
crease in left ventricular systolic pressure (Figure 1).
The muscle of the left ventricle hypertrophies in re-
sponse to the increase in systolic pressure to maintain
normal ejection fraction and normal cardiac output.
Ventricular hypertrophy without chamber dilatation
results in diastolic dysfunction (decreased compliance
and diastolic filling). Eventually, the contractile state
becomes depressed and the left ventricle dilates. At
this stage, the median survival of the patient is one
year (Figure 2).
Volume 93, Number 4 - September 1996
191
Table 1 - Complete Problem List
I.
Syncope of uncertain etiology
II.
Valvular Heart Disease
Etiology:
Degeneration
Anatomy:
Echocardiogram: calcific aortic stenosis, left ventricular
hypertrophy
Physiology;
Echocardiogram: calculated aortic valve area of 0.3 cm^,
moderate aortic insufficiency
Cardiac catheterization: 100 mmHg peak-to-peak gradient
Objective:
Severely compromised
Subjective:
Severely compromised
III.
Coronary Artery Disease
Etiology:
Atherosclerosis
Anatomy:
Cardiac catheterization: 75% diameter stenosis of the
mid-right coronary artery
Physiology:
Cardiac catheterization: normal left ventricular function
Objective:
Moderately compromised
Subjective:
Uncompromised
IV.
History of Hypercholesterolemia
V.
Prior Surgeries
A. Hernia repair
B. Hemorrhoidectomy
Syncope: Clues To
Diagnosis
The first question to
ask the patient with
syncope and aortic
stenosis is: "What were
you doing immediately
prior to passing out?" A
history of exertion is a
critical clue to the etiol-
ogy of the syncope.
Non-exertional syncope
may be related to the
aortic valve or the other
myriad causes of loss of
consciousness. Calcium
in the aortic orifice may
embolize to the cerebral
circulation and cause
brain ischemia. Calcium
may also extend into
the conduction system
causing transient atrio-
ventricular block. A
transient atrial arrhyth-
mia may abruptly lead
to a decrease in cardiac
output due to loss of
"atrial kick."
Four theories have been proposed to explain
exertional-related syncope in patients with aortic steno-
sis; carotid sinus reflex hyperactivity, abrupt failure of
the left ventricle, arrhythmia, and inappropriate re-
flex peripheral vasodilatation from ventricular barore-
ceptors.
Hyperactivity of the carotid sinus reflex. Marvin and
Sullivan (Arthur G. Sullivan, MD hailed from Hot
Springs, Arkansas) proposed that exertional-related
syncope was due to hyperactivity of the carotid sinus
reflex.^ It was later shown that carotid sinus massage
did not produce syncope in any of 19 patients stud-
ied, discounting this theory.'*
Abrupt failure of the left ventricle. Flamm and col-
leagues noted a sudden fall in cardiac output without
an appropriate increase in the systemic vascular resis-
tance in one patient undergoing erect exercise during
cardiac catheterization.® This hypothesis fell into dis-
favor with analysis of hemodynamic findings of 397
patients with aortic stenosis. In the group of 150 pa-
tients who had syncope, 59% had a left ventricular
systolic pressures >200 mm Hg and 14% had a cardiac
index < 2 L/min/m^.^ These findings dispel the theory
of left ventricular failure since syncope occurs at the
height of left ventricular pressure.
Arrhythmia. Arrhythmias have been proposed as a
cause of exertional-related syncope in patients with
aortic stenosis. Schwartz and colleagues studied nine
patients with aortic stenosis and syncope over a pe-
riod of six years. ^ They observed a variety of
arrhythmias including ventricular fibrillation and asys-
tole. Importantly, they found that the arrhythmias
developed after (not before) the onset of syncope. The
arrhythmias were therefore a secondary effect and not
the primary event leading to loss of consciousness.
Reflex peripheral vasodilatation. Reflex peripheral
vasodilatation appears to be the most plausible cause
for exertional-related syncope due to aortic stenosis.
Baroreceptors in the wall of the left ventricle are
sensitive to pressure or stretch. In some patients with
aortic stenosis, an increase in left ventricular pressure,
as with exercise, initiates an inhibitory impulse which
travels through the cardiac vagal afferent fibers to the
medulla producing vasodilatation and bradycardia. The
resulting hemodynamic collapse reduces cerebral per-
fusion and causes syncope.**
Grech and Ramsdale reported the hemodynamic
findings of a patient with syncope and aortic steno-
sis.’With exercise, there was an initial increase in blood
pressure, heart rate, and systemic vascular resistance.
With continued exertion, there was a progressive de-
192
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
dine in all of these hemodynamic pa-
rameters and the patient experienced
loss of consciousness. Replacement of
the aortic valve abolished the abnor-
mal hemodynamic changes and
"cured" the syncope.
Exertional-Related Syncope:
Response To Treatment
Wilmhurst and colleagues recently
reported the results of aortic valve re-
placement in patients with aortic
stenosis who had syncope.’” There
were no recurrent episodes of loss of
consciousness in patients who had
exertional-related syncope. However,
more than 50% of patients with
non-exertional syncope had recurrent
episodes. This study supports the
theory of inappropriate left ventricu-
lar baroreceptor responses in patients
with exertional-related syncope.
Figure 1 . Parasternal short axis view of a severely calcified tri-leaflet aortic valve. The
right and left atria are enlarged. (Echocardiogram courtesy of Nancy Patterson, BSN,
RDCS.) - Abbreviations: AO = aortic valve, LA = left atrium, PA = pulmonary artery,
PV = pulmonary valve, RA = right atrium, RVOT = right ventricular outflow tract,
TV = tricuspid valve.
Onset
severe
50 i
Age (years)
Conclusions
There are a variety of causes of
syncope in patients with aortic steno-
sis. A key finding is the relationship
of the syncopal episode to exertion.
One should not jump to the conclu-
sion that syncope at rest in a patient
with aortic stenosis is causally related.
In these patients, causes other than
aortic stenosis should be investigated.
Patients with exertional-related syn-
cope may have an abnormal barore-
ceptor activity and be symptomatically
improved with aorhc valve replacement.
80
60
c
^ 40
- Angina
Syncope
Failure
0 2 4 6
Av. survival (yrs)
References:
1. Hammarsten JF. Syncope in aortic steno-
sis (secondary source). Arch Intern Med
1951; 87:274-279.
2. Talley JD. The complete cardiac diagno-
sis. J Arkansas Med Society 1996;92:401-402.
3. Marvin HM, Sullivan AG. Clinical ob-
servations upon syncope and sudden death
in relation to aortic stenosis. Am Heart J 1935; 10:705-734.
4. Contralto AW, Levine SA. Aortic stenosis with special
reference to angina pectoris and syncope. Ann Intern Med
1937;10:1636-1653.
5. Flamm MD, Braniff BA, Kimball R, Hancock EW. Mecha-
nism of effort syncope in aortic stenosis (abstract). Circula-
tion 1967;35:11-109.
6. Lombard JT, Selzer A. Valvular aortic stenosis: Clinical
and hemodynamic profile of patients. Ann Intern Med
1987;106:292-298.
7. Schwartz LS, Goldfisher J, Sprague GJ, Schartz SP. Syn-
Latent period
(increasing obstruction,
myocardial overload)
Average death
Age (a)
Figure 2. Hemodynamic changes and life expectancy of patients with aortic stenosis who
have not undergone aortic valve replacement. (With permission of author and publisher.
Circulation 1968;38:61.)
cope and sudden death in aortic stenosis. Am J Cardiol
1969;23:647-658.
8. Johnson AM. Aortic stenosis, sudden death and the left
ventricular baroreceptors. Br Heart J 1971;33:1-5.
9. Grech ED, Ramsdale DR. Exertional syncope in aortic steno-
sis: evidence to support inappropriate left ventricular barore-
ceptor response. Am Heart J 1991;! 21 :603-606.
10. Wilmshurst FT, Willicombe PR, Webb-Peploe MM. Ef-
fect of aortic valve replacement on syncope in patients wi^h
aortic stenosis. Br Heart J 1993;70:542-543.
Volume 93, Number 4 - September 1996
193
<!l^rofessioria.l J^oiection Exclusively since 1899
To reach your local office, call 800-344-1899.
Sfcvtc Hakh WMcI
1
Information provided by the Arkansas Department of Health, Division of Epidemiology
Newly Reportable Diseases in Arkansas
On July 26, 1996, the Arkansas State Board of
Health voted to add certain diseases to the current list
of reportable diseases and conditions. These addi-
tions were recommended to the board by the Arkan-
sas Department of Health Division of Epidemiology,
and are in agreement with recommendations of the
Centers for Disease Control and Prevention (CDC),
and the Council of State and Territorial Epidemiologists.
The following diseases were added;
1. Drug-resistant Streptococcus pneumoniae.
Pneumococci are a leading cause of otitis media, pneu-
monia and meningitis, especially among children, per-
sons with debilitating medical conditions or immuno-
deficiencies, and the elderly. The prevalence of anti-
biotic resistance in the United States has increased dra-
matically over the past decade, with some rates of peni-
cillin resistance reported over 40%.
2. Cryptosporidiosis. This emerging infectious
diarrheal disease is caused by Cryptosporidium
parvum, a coccidian parasite. The reservoir of this
organism is the intestinal tract of human, cattle, and
other domestic animals, and it is present in much of
the surface waters in the United States. The infection
is most severe in immunosuppressed persons, but
outbreaks caused by contaminated community water
systems have involved thousands of normal individuals.
3. Group A Streptococcal Invasive Disease. Ne-
crotizing fasciitis is the most prominent manifestation
of invasive disease caused by Group A Streptococci.
The CDC has recommended that this condition be
made reportable, as the number of cases occurring in
the United States is unknown.
4. Hantavirus disease. As of May 3, 1996, 133
cases of hantavirus pulmonary syndrome have been
reported in the United States. This is an acute zoonotic
disease characterized by fever, myalgia and gastrointes-
tinal complaints followed by the abrupt onset of respi-
ratory distress and hypotension. The fatality rate has
been approximately 50%. Cases have been reported
from 24 states, including Texas, Louisiana, and Florida.
Although no human cases have been identified in Ar-
kansas, one rodent from the Garland County area was
found to have hantavirus antibodies.
5. Haemophilus influenzae Invasive Disease.
Meningitis caused by H. influenzae is currently re-
portable, but epiglottitis, pneumonia, septic arthritis,
cellulitis, empyema, and osteomyelitis are not. To be
consistent with national reporting criteria, Arkansas
reports should include all cases of invasive disease.
6. Infant Botulism. The CDC has recommended
that infant botulism be reported separately from other
botulism cases.
7. Hepatitis C/Non- A/Non-B. Hepatitis C has been
increasingly recognized as a clinical entity with the
advent of more specific tests. This is an important
cause of acute and chronic hepatitis and serious se-
quelae. The CDC recommends that patients with a
positive Hepatitis C serology and liver transaminases
2-1/2 times normal be reported as a case of C/Non-A/
Non-B Hepatitis.
8. Vancomycin-resistant enterococci. Vancomy-
cin-resistant enterococci (VRE) have emerged as im-
portant nosocomial pathogens in recent years. Both
the numbers of VRE and the number of outbreaks
caused by VRE reported to the CDC have increased.
The epidemiology of VRE is not well understood, and
increased surveillance and study is necessary to their
control.
These and other reportable diseases should be re-
ported by calling 1-800-482-8888. For a listing of all
reportable diseases and conditions in Arkansas, call
661-2893 in Little Rock or 1-800-482-5400 ext. 2893 dur-
ing normal business hours.
Volume 93, Number 4 - September 1996
195
Reported Cases of Selected Reportable Diseases in Arkansas
Profile for June 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
June 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1995
Total
Reported
Cases
1994
Campylobacteriosis
21
90
78
67
153
187
Giardiasis
10
56
49
39
131
126
Shigellosis
4
39
61
81
176
193
Salmonellosis
39
151
109
98
332
534
Hepatitis A
27
263
186
43
663
253
Hepatitis B
4
45
33
26
83
60
HIB
0
0
5
2
6
5
Meningococcal Infections
0
23
24
33
39
55
Viral Meningitis
0
11
13
36
31
62
Lyme Disease
5
17
7
10
11
15
Rocky Mountain Spotted Fever
3
5
11
7
31
18
Tularemia
3
10
16
16
22
23
Measles
0
0
2
1
2
5
Mumps
0
0
4
4
5
7
Rubella
0
0
0
0
0
0
Gonorrhea
***
***
2532
3749
5437
7078
Syphilis
★ **
***
826
725
1017
1096
Legionellosis
0
0
5
8
5
16
Pertussis
0
3
25
19
59
33
Tuberculosis
18
108
106
119
271
264
*** Unavailable at date of submission
196
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Rogers, AR 72756
636-1700
Statewide
1-800-467-1333
Arkansas HIV/AIDS Report
1983-1996
HIV In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: Qjunty of residence may
change from date of HIV test to date
of AIDS diagnosis.
Benton jj'ssl
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Baxterl
Marion
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Washington!
1 1 Lawrenc^i
indepen dencep
CrawfordT
ifjohnson]-
FranklinI
{ rjacksonj:
Crittender^
I CrossIpTsI
ijj Conwayj^
Sebastian]
Faulkn^
Woodruff!
St. Franci^
I Prairier :
Pulaskij
Monroe]
Garland!
I Montgomery]
"[Phillip
I Arkansa^:
Jefferson!
Lincoln!
Sevierl
Clevelandl
Desha]
Hempstead
Nevada]
Calhoun]
Ouachita]
Chicot]
j^rColunibial
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i:j Lafayett^
I ScottI
HIV+ CASES
REPORTED
□ 1 to 3
□ 4 to 49
O 50 to 99
■ 101 to 1281
I County of residence at the time of test for the 3,631 Arkansans reported to be HIV+ (7/12/96)1
HIV
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
1
Male
100
215
248
413
400
392
352
367
338
172
2,997
83
X
Female
8
26
37
68
85
81
94
90
91
54
634
17
Under 5
1
1
2
8
13
6
3
7
2
1
44
1
5-12
0
1
1
5
1
2
1
0
1
0
12
0
13-19
0
7
8
14
19
25
11
22
12
17
135
4
20-24
12
40
52
71
44
49
64
60
47
21
460
13
25-29
21
70
71
112
105
107
111
85
78
41
801.,,
22
A
30-34
25
50
64
116
120
111
91
102
101
44
824
23
G
35-39
19
36
40
80
88
68
77
69
81
45
603
17
E
40-44
16
17
17
43
50
41
47
50
46
24
351
10
45-49
6
8
18
13
20
26
18
27
24
12
172
5
50-54
2
1
5
8
14
14
10
12
17
10
93
3
55-59
1
3
4
6
3
13
6
7
5
6
54
1
60-64
1
0
1
1
2
6
5
9
8
1
34
1
65 and older
4
2
1
2
3
5
2
7
7
4
37
1
R
White
87
170
174
328
298
293
278
259
260
112
2,259
62
A
Black
21
69
108
151
184
173
163
184
159
101
1,313
36
C
Hispanic
0
1
3
1
3
4
1
7
3
2
25
1
E
Other/Unknown
0
1
0
1
0
3
4
7
7
11
34
1
Male/Male Sex
65
138
143
243
247
261
242
229
161
63
1 792
49
Injection Drug User (IDU)
13
30
48
74
96
75
65
71
50
11
533
15
R
Male/Male Sex & IDU
19
23
24
32
30
34
26
23
25
9
245
7
1
Heterosexual (Known Risk)
5
25
26
59
64
68
100
94
59
23
523
14
S
Transfusion
5
5
4
6
8
10
0
2
2
0
42
1
K
Perinatal
1
1
2
8
13
8
4
7
0
0
44
1
Hemophiliac
0
0
6
18
5
6
2
3
5
0
45
1
Undetermined
0
19
32
41
22
11
7
28
127
120
407
11
HIV CASES BY YEAR
108
241
285
481
485
473
446
457
429
226
3,631
100
Arkansas Department of Health HIV/AIDS Surveillance Program
198
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1996
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a jrerson tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directorsof
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: County of residence may
change from date of HI V test to date
of AIDS diagnosis.
AIDS
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
1
Male
85
77
70
170
176
250
334
253
238
130
1,783
87
X
Female
5
6
10
20
25
35
64
42
36
31
274
13
Under 5
0
1
1
6
6
3
2
1
2
0
22
1
5-12
0
1
0
1
1
0
1
0
2
1
7
0
13-19
0
0
0
4
3
2
4
3
1
2
19
1
20-24
7
5
11
11
14
14
31
22
11
9
135
7
25-29
24
22
13
44
43
67
78
45
47
22
405
20
A
30-34
20
21
21
47
42
73
98
81
75
42
520
25
G
35-39
19
15
20
31
38
55
80
52
49
36
395
19
E
40-44
10
7
4
21
35
28
49
39
35
25
253
12
45-49
5
3
3
14
6
24
28
22
17
11
133
6
50-54
- i
1
2
5
6
7
10
12
15
3
62
3
55-59
2
2
4
1
4
8
8
5
6
5
45
2
60-64
.... ...T',
1
1
1
1
2
6
10
5
1
29
1
65 and older
i
4
0
4
2
2
3
3
9
4
32
2
R
White
74
61
58
141
134
206
273
190
174
84
1,395
68
A
Black
16
20
21
47
66
75
121
102
97
75
640
31
C
Hispanic
0
1
0
0
1
3
3
2
3
2
15
1
E;;::
Other/Unknown
0
1
1
2
0
1
1
0
0
7
0
Male/Male Sex
55
59
50
122
120
183
237
166
135
66
1,193
58
Injection Drug User (IDU)
12
4
11
18
29
45
70
46
47
10
292
14
R
Male/Male Sex & IDU
16
6
6
18
17
21
27
23
20
10
164
8
1
Heterosexual (Kno\wn Risk)
5
3
7
11
12
24
52
41
34
16
205
10
S
Transfusion
2
7
3
7
11
3
2
4
3
1
43
2
K
Perinatal
0
1
1
6
6
3
3
1
3
0
24
1
Hemophiliac
0
1
1
5
5
4
5
6
7
2
36
2
Undetermined
0
2
1
3
1
2
2
8
25
56
100
5
AIDS CASES BY YEAR
90
83
80
190
201
285
398
295
274
161
2,057
100
Arkansas Department of Health HIV/AIDS Surveillance Program
Volume 93, Number 4 - September 1996
AIDS In
Arkansas
rt — \ 13 V- ra icie^di ^ ^ ^
TTofr
Calhouni;
Ouachilafei
■ (Dy
I'Ashieyl r
AIDS CASES
REPORTED
□ 0
□ 1 to 3
n 4 to 49
■ 50 to 675
I Of the 3,631 Arkansans reported to be HIV+, 2,057 have been diagnosed with AIDS. (7/12/96)1
199
New Members
ASHDOWN
Covert, George Krueger, Family Practice/Emer-
gency Room. Medical Education, University of
Autonoma, Guadalajara, Jalisco, Mexico, 1975. Intern-
ship, Muhlenburg Hospital, Plainfield, NJ, 1976. Resi-
dency, St. Barnabes Medical Center, 1977.
AUGUSTA
Moore, Jesse Daniel, Eamily Practice. Medical
Education, UAMS, 1993. Internship/Residency, South-
west Family Practice Residency, Texarkana, 1994/1996.
Board pending.
BRADFORD
Knowles, Glen Carter, Family Practice. Medical
Education, Oklahoma State University College of Medi-
cine, Tulsa, 1993. Internship/Residency, AHEC-Pine
Bluff, 1994/1996.
DANVILLE
Isely, William A. Medical Education, Universidad
Autonoma de Guadalajara, Jalisco, Mexico, 1982. In-
ternship/Residency, Lutheran Medical Center, St.
Louis, MO, 1984/1985.
EL DORADO
Moore, John H., General Surgery. Medical Edu-
cation, UAMS, 1964. Internship, Grady Memorial Hos-
pital, 1965. Residency, LSU-Charity Hospital, New
Orleans, 1969. Board certified.
EUDORA
Doshi, Sangeeta H., Medical Education, M.g.m.
Medical College, India, 1988. Internship M.y. Hospi-
tal, India, 1989. Residency, Mercy Hospital, Toledo,
Ohio, 1994.
FAYETTEVILLE
Allen, Bernagie Eual, Family Practice. Medical
Education, UAMS, 1992. Internship, AHEC-Pine Bluff,
1993. Residency, AHEC-NW, Fayetteville, 1995.
Garibaldi, Byron Thomas, Family Practice. Medi-
cal Education, University of Texas Medical Branch,
Galveston, 1993. Internship/Residency, St. Joseph Fam-
ily Practice Residency Program, 1994/1996.
FORREST CITY
Hashmi, Shakeb, Internal Medicine. Medical Edu-
cation, Aga Khan University, Pakistan, 1992. Intern-
ship/Residency, University of Tennessee, Memphis,
1994/1996.
200
FT. SMITH
Foreman, Riley D., Cardiology. Medical Educa-
tion, University of Health Sciences College of Osteo-
pathic Medicine, Kansas City, MO, 1984. Internship,
Still Memorial Hospital, 1985. Residency, Naval Hos-
pital Oakland, 1991. Board certified.
Handley, David Lynn, Radiology. Medical Edu-
cation, University of Texas Medical Branch, Galveston,
1992. Residency, University of Texas Southwestern,
Dallas, 1996. Board certified.
McMicheal, Wanda V., Family Practice. Medical
Education, University of Oklahoma College of Medi-
cine, Oklahoma City, 1993. Internship/Residency, St.
Joseph's, Wichita, Kansas, 1994/1996.
HOT SPRINGS
Hill, Harold Randall, Family Practice. Medical
Education, UAMS, 1993. Internship/Residency, AHEC-
Pine Bluff, 1994/1996.
Waters, Samuel Gregory, Emergency Medicine.
Medical Education, UAMS, 1991. Internship/Residency,
UAMS. Board pending.
JONESBORO
Labor, Penny Megison, Radiology. Medical Edu-
cation, Louisiana State University Medical Center,
Shreveport, 1990. Internship/Residency, Louisiana
State University Medical Center, Shreveport, 1991/1995.
Board certified.
Pryor, Shapard Hanner, Jr., Anesthesiology. Medi-
cal Education, UAMS, 1993. Internship/Residency,
UAMS, 1993/1996.
Templeton, Gary L., Pulmonary Medicine. Medi-
cal Education, UAMS, 1987. Internship/Residency,
UAMS, 1988/1990. Board certified.
LITTLE ROCK
Angtuaco, Sylvia Santos-Ocampo, Pediatric Car-
diology. Medical Education, Brown University, Provi-
dence, Rhode Island, 1989. Internship/Residency, Yale-
New Haven Hospital, 1990/1992. Board certified.
Contrucci, Ann L., Pediatrics. Medical Education,
Medical College of Georgia, Augusta, 1993. Internship/
Residency, UAMS/Arkansas Children's Hospital, 1994/
1996. Board eligible.
Henry, William Bradley, Anesthesiology. Medi-
cal Education, UAMS, 1984. Internship/Residency,
UAMS, 1985/1987. Fellowship, Arkansas Children's
Hospital and VA Medical Center, 1988. Board certified.
Johnson, Clifton, Pulmonary/Critical Care. Medi-
cal Education, UAMS, 1989. Internship/Residency,
Emory University School of Medicine, 1990/1992. Board
certified.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Shields, Eddie Wayne, Allergy and Immunology.
Medical Education, University of Arkansas College of
Medicine, 1991. Internship/Residency, UAMS,
Texarkana, 1992/1994. Board eligible.
MONTICELLO
Gordon, Leonard R, Radiology. Medical Educa-
tion, University of Pennsylvania School of Medicine,
Philadelphia, 1977. Internship, Georgetown Univer-
sity Hospital, Washington D.C., 1978. Residency,
Temple University Hospital, Philadelphia, PA, 1982.
Fellowship, University of Pennsylvania Hospital, Phila-
delphia, 1983. Board certified.
MOUNTAIN VIEW
Beebe, William Edward, Family Practice. Medical
Education, Louisiana State University Medical Cen-
ter, Shreveport, 1993. Internship/Residency, AHEC-
NE, Jonesboro, 1994/1996. Board pending.
NORTH LITTLE ROCK
Sangster, Michael Gerard, Dermatology. Medical Edu-
cation, UAMS, 1992. Internship/Residency, UAMS,
1993/1996.
PINE BLUFF
Cash, James Steven, Internal Medicine. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
1994/1996.
SEARCY
Mullens, Mark Lee, Cardiovascular Medicine.
Medical Education, University of Alabama School of
Medicine, Birmingham, 1989. Internship/Residency,
UAMS, 1990/1992. Board certified.
SILOAM SPRINGS
Allard, Mark Michael, Orthopedic Surgery. Medi-
cal Education, UAMS, 1991. Internship/Residency,
UAMS, 1992/1996.
VAN BUREN
Katz, Stephen Jerome, General Surgery. Medical
Education, Dalhousie University, Halifax, Nova Scotia,
Canada, 1967. Internship, Victoria General, Canada,
and Mount Sinai Hospital, New York, NY, 1968. Resi-
dency, Boston University Med. Ctr, 1976. Board certified.
OUT OF STATE
Sarna, Paul Duane, Family Practice. Medical Edu-
cation, UAMS, 1993. Internship/Residency, Southwest
Family Practice Residency, 1994/1996.
RESIDENTS
Adams, Lennox Roosevelt, General Surgery. Medi-
cal Education, St. George University School of Medi-
cine, Grenada, West Indies, 1994. Internship, UAMS,
1995. Residency, UAMS.
Bailey, Thomas O., Family Practice. Medical Edu-
cation, UAMS, 1996, Internship, AHEC-Pine Bluff.
Blackwood, Jann Belle, Family Practice. Medical
Education, University of Osteopathic Medicine &
Health Sciences, Des Moines, Iowa, 1996. Internship,
UAMS.
Cain, Stephen Richard. Medical Education,
UAMS, 1996. Residency, AHEC-El Dorado.
Cruz, Lisa Renee Desbien, Pathology. Medical
Education, Louisiana State University Medical Cen-
ter, Shreveport, 1992. Internship/Residency, Louisiana
State University Medical Center, Shreveport, 1993/1996.
Residency, UAMS.
Darby, Scott Jason. Medical Education, UAMS,
1996, Residency, UAMS, AHEC-Pine Bluff.
Erwin, Steven Michael, Family Practice. Medical
Education, UAMS, 1996. Internship/Residency AHEC-
Pine Bluff.
Fant, Jerri S., General Surgery. Medical Educa-
tion, Duke University, Durham, NC, 1992. Internship/
Residency, UAMS.
Gordon, Anthony K., Family Medicine. Medical
Education, UAMS, 1996, Residency, UAMS.
Gordon, Gayle S., Family Practice. Medical Edu-
cation, UAMS, 1996, Residency, UAMS.
Handloser, Holly Holland. Medical Education,
UAMS, 1996, Residency, AHEC-South Arkansas.
Hartman, Arthur Richard. Medical Education,
University of South Florida College of Medicine,
Tampa, 1996.
Huey, Sandra Sheiron, Family Medicine. Medical
Education, University of Health Sciences College of
Osteopathic Medicine, Kansas City, MO, 1996. Intern-
ship/Residency, AHEC-Pine Bluff.
Kidd, Tracy Lyon, Ob/Gyn. Medical Education,
Baylor College of Medicine, Houston, TX, 1996. In-
ternship/Residency, UAMS.
Ledbetter, Johnny Roger, Jr., Pediatrics. Medical
Education, UAMS, 1995, Internship/Residency, UAMS-
Arkansas Children's Hospital.
Malone, Mark Steven. Medical Education, Texas
A&M University College of Medicine, College Station,
TX, 1993. Internship, University of Pittsburgh. Resi-
dency, AHEC-South Arkansas.
Marshall, Marilyn Dianne, Family Medicine.
Medical Education, University of Michigan Medical
School, Ann Arbor, 1996. Internship/Residency, AHEC-
South Arkansas.
McLeod, Michael Reilly. Medical Education, Uni-
versity of Texas Southwestern Medical School, Dallas,
1996.
Mohan, Kumaran K, Family Medicine. Medical
Education, Calicut Medical College, 1979. Internship,
Calicut Medical College. Residency, El Dorado.
Over, Darrell Ray, Family Medicine. Medical
Education, University of Texas School of Medicine at
San Antonio, 1996, Residency, AHEC-Pine Bluff.
Parcon, Paul Jeffrey, Family Practice. Medical
Education, University of the East, Ramon Magsaysay
Memorial Medical Center, Manila, Philippines, 1987.
Volume 93, Number 4 - September 1996
201
Residency, AHEC-South Arkansas.
Thomas, Lynn C., Psychiatry. Medical Education,
UAMS, 1995, Residency, UAMS.
Wilkin, Tim T, Eamily Practice. Medical Educa-
tion, University of Health Sciences College of Osteo-
pathic Medicine, Kansas City, MO, 1996. Internship/
Residency, AHEC-Pine Bluff.
Willhite, Andrea Kay. Medical Education, Uni-
versity of Osteopathic Medicine and Health Sciences,
Des Moines, Iowa, 1996. Internship, UAMS.
Williams, Nancy Kay. Medical Education, UAMS,
1996, Residency, AHEC-Pine Bluff.
Wooten, R. Gregory, Psychiatry. Medical Educa-
tion, UAMS, 1996, Residency, UAMS.
STUDENTS
Shannon Howard Brownfield
Bradley David Bryant
Gwendolyn Michelle Bryant
Rachel Clare Campbell
Todd Michael Clements
Robert Daniel Cullen
Minh-Tri Danny Dang
Richard Keith Davis, Jr.
Elvin Lephiew Dennington
Mary Frances Douglas
Johnna Louise Duke
Kevin Sam Earl
Clinton Brough Edwards
Philip Ellis Ferguson
Shirley Fong
Patrick J. Fox
Vianne R. France
Jon David Fuller
Caleb Oakes Gaston
Forrest Daniel Glover
Dane Andrew Gluenck
Eric Houston Gordon
Dehra Anne Harris
Thomas Michael Hillis
Thomas Wade Hinton
William McCall Hogan, Jr.
Cheryl Ann Holland
David Glenn Johnson
Micheal Knox
Jadd Wadi Koury
Barrett Dean Lewis
Sanford B. McCallum
Karen Leslie McNiece
Janette Elaine Myers
Ezechiel Raymond Nehus
Marshall James Newcity
Jonathan Gardner Norcross
David Jason Oberste
Michael B. Pafford
Jong Chan Park
Jason Darrel Parker
Kristina Michele Phillips
Michael Ellis Pinchback
Ashley Sloan Ross, III
Douglas Bryan Ross
Kenneth Morgan Sauer
Keith Oliver Schluterman
Caroline Clements Smith
David Lucas Smith
Elizabeth Anne Storm
Robert Thomas VanHook
James Edward Wade
Brian James West
Jennifer Leigh Woods
202
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
David Marshfield, M.D., Editor
Authors
N. Karol Anderson
David Marshfield, M.D.
HISTORY:
Case 1 ; 45-year-old white female presents with a palpable, non-fixed mass of the left breast. Mammography was
inconclusive due to marked density of the fibroglandular tissue in this relatively young female. Breast ultrasound was
performed as represented in Figure 1 .
Case 2: 52-year-old black female presents with a palpable non-fixed mass of the right breast. Due to hormone
supplementation and extreme density of the patient’s mammograms, mammography was inconclusive. Breast ultra-
sound was performed and the findings are represented in Figure 2.
Case 3: 49-year-old white female presents with a palpable non-fixed mass of the right breast. Mammography
was inconclusive secondary to the increased density of the patient’s breast tissue. Breast ultrasound was performed
in this patient and is represented in Figure 3.
RADIOGRAPHIC FINDINGS:
Figure 1; There were two closely approximated lesions.
The internal echo texture of both lesions was completely
anechoic, and these lesions were well circumscribed and thinly
encapsulated. These lesions demonstrated enhanced through
transmission and thin edge shadows.
Figure 2: The lesion was well circumscribed and smoothly
ellipsoid in shape with a horizontal diameter greater than the
AP dimension (wider than tall). There was a thin, echogenic
pseudocapsule around this nodule suggesting a pushing,
non-invasive leading edge (not infiltrative). Not only was the
inner border of the capsule well circumscribed, but the outer
border was also well defined.
Figure 3: The breast ultrasound examination revealed a
markedly hypoechoic mass with irregular, angular margins.
The lesion appeared to be “taller-than-wide,” and there was a
spiculated capsule with evidence of duct extension (as indi-
cated by the white arrow). Marked shadowing was also noted.
BREAST MALIGNANCr
Figure 3
Volume 93, Number 4 - September 1996
203
Benign Simple Cyst, Benign Fibroadenoma
& Malignant Carcinoma of the Breast
DIAGNOSIS:
Case 1: Benign simple cyst.
Case 2; Benign fibroadenoma.
Case 3: Malignant carcinoma of the breast.
DISCUSSION:
Previously the role of ultrasound in breast examination has been limited to differentiation of simple, benign cysts
from other breast disease. Recent improvement in ultrasound equipment and technology now make it possible to
diagnosis solid masses as being benign or malignant with an extremely high degree of certainty, thereby eliminating
a number of unnecessary biopsies for benign, solid breast masses. One such ultrasound system is the Advanced
Technology Laboratories (ATL) High Definition Imaging (HDI) digital ultrasound system which was the first system to
receive FDA approval of it’s pre-market approval (PMA) for imaging of solid breast tumors. The PMA application was
based on findings of an international multi-center study that involved more than 1000 women with breast lesions. The
participants underwent imaging with the ATL HDI digital ultrasound system. The examination took approximately 15
minutes and was performed following diagnostic mammograms which revealed suspicious breast lesions. Only solid
lesions were included in the study; simple cysts found on conventional ultrasound were excluded. Based on the
results of the mammogram and/or clinical examination, the lesion was assigned a level of suspicion score of 1 to 5 as
follows: 1=benign; 2=probably benign; 3=indeterminate; 4=probably malignant, and 5=malignant.
The mass was also scored under a similar classification system based on ultrasound findings obtained from the
HDI examination. A similar grading system was employed pertaining to the color doppler signals obtained from the
solid breast masses. Ultimately, a "physician’s call" of benign or malignant was made based on all of the information
obtained from the clinical, mammographic and ultrasound findings. All lesions underwent biopsy and pathologic
confirmation. The receiver-operator characteristics (ROC) analysis showed a statistically significant improvement
when ultrasound was used following mammography compared to mammography alone in discriminating solid breast
masses.
The following are selected excerpts from breast ultrasound syllabi and lectures recently presented by Dr.
David Marshfield.
Most physicians realize the importance of early diagnosis of breast carcinoma. With the exception of radiologists,
most physicians are unaware of the enormous limitations of mammography in accurately diagnosing breast pathol-
ogy. Mammography has a false positive rate of 80 to 90%. In other words, out of every 100 patients who undergo
biopsy of mammographically suspicious lesions, only 10 to 20 have malignancy. The other 80 to 90 patients have
benign disease which would not require biopsy if better diagnostic tests were available. Ultrasound, although not
appropriate as a screening tool, is becoming an excellent diagnostic test to better classify abnormal clinical and
mammographic findings. Previously the role of ultrasound was limited to differentiating cysts from solid masses, with
all solid or indeterminate masses requiring biopsy. ATL is the first in the industry to pursue ultrasound as a modality
capable of differentiating solid breast masses. The recent preliminary multi-center study by ATL has shown that 40%
of biopsies can be eliminated by improved ultrasound techniques. Even as ultrasound is enhancing the specificity in
diagnosing breast abnormalities, advances in breast MRI are also promising.
1.) BUS General Goals
Mammography can be used for diagnosis or breast cancer screening. Breast ultrasound (BUS), on the other
hand, is used strictly for diagnosis. The general goal of BUS is to arrive at a more specific diagnosis. If the more
specific diagnosis is that of a typically benign lesion such as a simple cyst, BUS can prevent unnecessary biopsy
and can also obviate the need for follow-up diagnostic mammography. If the more specific diagnosis is that of a
malignant or nonspecific lesion, or of a symptomatic benign lesion, BUS is superb at guiding needle procedures
including: needle localization for excisional biopsy, cyst aspiration, and core-needle biopsy. In the process of identify-
ing appropriate mammographic and/or clinical indications for BUS and closely correlating BUS findings with clinical
and mammographic findings, the breast sonographer typically improves mammographic and clinical skills. BUS
also occasionally demonstrates a malignancy which is neither clinically nor mammographically apparent, but finding
cancers is only a minor goal of BUS.
204
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
2. ) Indications
Since BUS is a diagnostic rather than a screening procedure, it is targeted to a specific clinical or focal mam-
mographic finding in the vast majority of patients.
BUS should be performed on palpable lumps when the mammogram In the area of the lump is negative or
nonspecific. Furthermore, there should be water density tissue by mammography in the area of the palpable lump for
ultrasound to add any useful information. If the entire breast or the entire quadrant in which the palpable abnormality
lies contains only fatty tissue on mammograms, the mammogram will not miss any significant lesions and the BUS
will not find any significant lesions which the mammogram has missed. If there is a mammographically visible and
obviously malignant lesion in the area of the palpable abnormality, it is unlikely that BUS will add enough useful
information to alter treatment.
BUS should be also be performed when there is a focal mammographic nodule or mass which has benign or
nonspecific characteristics. Mammography cannot distinguish between cyst and solid, even for
well-circumscribed lesions. If the mammographic lesion is obviously malignant, BUS will generally not add enough
additional information to alter treatment. In such cases, however, BUS might still be used to guide needle-localization
or needle-biopsy because it is generally quicker than mammographic guidance.
The vast majority of BUS examinations will be performed to evaluate focal palpable or mammographic abnormali-
ties. Such examinations are usually limited to the general area of the clinical or mammographic abnormality. There
are, however, occasional circumstances in which whole-breast examinations may be performed. These include; 1)
breast secretions; 2) suspected leaks from silicone implants; 3) follow-up of multiple known mammographic and/or
sonographic lesions; 4) patients who refuse mammography (usually because of radiation phobia); 5) strong family
history of breast cancer and radiographically dense breast tissue; 6) metastases thought to be of breast origin, but
negative clinical exam and mammography, and 7) to exclude multicentric malignancy when lumpectomy and radia-
tion are an option for a known clinically or mammographically evident malignancy.
Contrast enhanced MRI is being investigated for applications #2 - #7 and may eventually replace BUS for these
“whole-breast” applications.
3. ) BUS Correlation with Clinical Findings and Mammograms
When the main indication for BUS is a palpable lump, it is imperative that the lump be palpated while
being scanned. Breast biopsy can be avoided if it can be shown that the lump is due to a simple cyst or due to
fibroglandular tissue. Both can cause palpable lumps or ridges. Merely showing a simple cyst or echogenic fibroglandular
tissue in the general vicinity of a palpable lump, however, is inadequate proof that it is the cause of the lump. Simple
cysts are so common in some age groups that they are virtually a variant of normal. Fibroglandular tissue, of course,
is present in at least some parts of the breasts in the vast majority of all women - especially those who are within the
reproductive years and even in postmenopausal women who are undergoing hormonal replacement therapy. Both
simple cysts and fibroglandular elements are frequently incidental findings and not the cause of the palpable abnor-
mality. Only by palpating a cyst or focal collection offibroglandulartissuewhile weare demonstrating it sonographically
can we be sure that it is the cause of the palpable abnormality.
When the main indication for BUS is a mammographic nodule, mass, or focai asymmetricai density, it is
essential that size, shape, location, and density of surrounding tissues are the same on mammograms and
uitrasound. As for the palpable lumps, merely showing a simple cyst or focal collection of fibroglandular tissues does
not prove that either is the cause of the mammographic abnormality. Either could easily be an incidental finding,
especially if the breasts are mammographically dense or if there are multiple mammographic densities. Only if the
size, shape, location, and density of surrounding tissues are similar on mammography and BUS can we be sure that
a simple cyst or fibrous pseudotumor is the cause of the mammographic density.
When correlating BUS with mammography, one should compare the CC view of the mammogram with
the transverse view on BUS. The shape of a mammographic lesion will be easier to reproduce sonographically if the
scan plane is identical to the projection plane of the mammogram. The transverse BUS sonotomographic plane very
consistently reproduces the projection of the CC mammogram. The MLO view of the mammogram may vary from 30°
to 60°. It is difficult to reproduce the exact degree of obliquity on the BUS that was used on the MLO view of the
mammogram.
4. ) BUS Equipment
BUS equipment must have excellent spatial and contrast resolution. Both axial and lateral components of spatial
resolution must be exquisite. Broad-band, high-frequency linear electronically-focused probes currently offer the best
combination of spatial and contrast resolution for BUS.
Excellent axial resolution is important in identifying normal structures which course parallel to the skm
Volume 93, Number 4 - September 1996
205
(such as mammary ducts and the fascial planes surrounding the mammary zone) and in identifying the
characteristics of the capsules around cysts and solid nodules. Equipment with adequate axial resolution should
allow identification of normal ducts in the periareolar regions in most breasts. If you never see these, the equipment
you are using has inadequate axial resolution. The axial component of spatial resolution is dependent primarily upon
nominal probe frequency, bandwidth, and burst length. Axial resolution is proportional to probe frequency. The higher
the probe frequency, the shorter the wavelength. The shorter the wavelength, the better the axial resolution. The
relationship between probe frequency and axial resolution holds for any given burst length. The longer the burst
length, the more wavelengths are sent out in each pulse. If burst length is increased, axial resolution is decreased.
Axial resolution improves with wider bandwidths. The best axial resolution is achieved with a high-frequency, broad
bandwidth probe when the burst length is short.
Lateral resolution at all depths within the breast is important in order to minimize volume averaging of surrounding
normal breast tissues with pathological lesions. Such volume averaging may cause mischaracterization of small
cystic lesions as solid and may even cause small solid lesions to be indistinguishable from surrounding tissues.
Lateral spatial resolution is also a complex subject. For linear probes there are two planes which determine lateral
resolution; the long axis and the short (elevation plane focus).
The long axis of the linear probe can be electronically focused. Continuous electronic focusing may be done on
receive or transmit phases. The degree of electronic focusing upon receive depends upon many factors, including: 1 )
number of channels, 2) aperture size, 3) number of elements, 4) number of scan lines, and 5) apodization. In general,
lateral resolution improves with increasing number of channels, increasing aperture size, increasing number of ele-
ments in the transducer, and increasing scan lines. Some probes with fewer elements compensate by interpolating
scan lines between elements (half-line scanning). In general, most manufacturers do an excellent job of electronically
focusing upon receive. Electronic focusing on transmit depends on many of the same factors as receive focusing but
has been more limited. It depends upon the number of transmit zones. In general, the more transmit zones, the better
the lateral resolution. Increasing the number of transmit zones, however, decreases frame rate. In general, many
transmit focal zones in the first 2 cm are very beneficial in BUS. Some high frequency probes, however, concentrate
too many transmit zones below 1.5 cm. for optimal breast imaging. One manufacturer has recently implemented
continuous electronic focusing upon transmit as well as receive. The optimal BUS probe has a large aperture, high
scan line density, continuous electronic focusing on receive, and either numerous very superficially located transmit
zones or continuous electronic focusing upon transmit.
5. ) BUS Technique
The patient is positioned in a supine position with the ipsilateral hand behind the head. The patient is rolled into a
contralateral posterior oblique position to a degree which minimizes breast thickness in the quadrant being scanned.
Lesions in the medial quadrants may be best scanned in straight supine position. Lesions in the lateral quadrants
require the greatest degree of contralateral posterior obliquity. Generally, greater degrees of obliquity are required for
larger breasts.
This positioning accomplishes two things: 1) The breast is thinned to the greatest extent possible, so that
the high frequency, near-field probes used adequately penetrate to the chest wall and so that the focusing character-
istics of the probe are optimized; and 2) The tissue planes of the breast, which are conical in the upright and prone
positions, are pulled into a plane which is parallel to the skin line. This minimizes critical angle shadowing and
improves penetration and prevents degradation of focusing characteristics. There is one additional advantage to this
positioning. It is very similar to the position the patient will be in during open excisional biopsies, especially important
when using ultrasound to guide needle localizations.
Solid lesions are scanned in radial and antiradial planes rather than in routine longitudinal and transverse
planes. The reasons for this will be discussed later. Radial plane images are abbreviated “RAD” and antiradial planes
are abbreviated “AR.”
6. ) Simple Cysts
Breast cysts can be classified as simple or complex. Simple cysts are completely anechoic, well-circumscribed
and thinly-encapsulated. They show enhanced through transmission and thin edge shadows. Only if a cyst meets all
of these criteria can it be called a simple cyst. If strict criteria for a simple cyst are met, however, there is virtually no
chance of malignancy. It is unnecessary to biopsy, aspirate, or even follow-up such a cyst. Enhanced through trans-
mission is the most variable and difficult to demonstrate of these simple cystic characteristics. It can be especially
difficult to demonstrate enhanced through-transmission for small and/or deep cysts. In many instances a special
effort to scan the cyst exactly perpendicular to the anterior wall is necessary to demonstrate this enhanced through
transmission. For deep cysts which lie adjacent the chest wall, coronal scanning planes can be helpful. Since en-
206 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
HMn
hanced through-transmission is an artifact of the time-gain curve (TGC), using a steeper TGC can sometimes make
it more obvious.
Simple cysts which are under pressure can be palpated and are roughly spherical in shape. Many cysts are not
under pressure at the time of BUS and cannot be palpated. They may appear flattened and ovoid in the AP dimension
during scanning. These cysts will have the same maximum diameter on ultrasound as they do on mammograms
(when mammographic magnification is taken into account), but will generally have a smaller mean diameter on BUS
than they do on mammograms because they are only being compressed in one plane during the BUS, but are being
compressed in two planes during two-view mammograms.
If the indication for BUS is a palpable lump, the cyst should be palpated while it is being scanned to make sure
that it is the cause of the palpable lump. If the indication for BUS is a mammographic nodule or mass, the size, shape,
location, and density of surrounding tissues should be the same for BUS and mammography.
7. ) Complex Cysts
Complex breast cysts represent a very heterogeneous group of entities. The term “complex” is not as informative
or helpful in BUS as it is for sonography of the kidneys. There is a spectrum of complex cysts, some of which have
implications little different from simple cysts, and others which carry a significantly higher risk of malignancy than
some solid nodules. We continue to use the term “complex cyst” in reporting BUS results, but always modify the term
with a description of the characteristics which require such a classification. Complex cystic types include: 1) mobile
diffuse, low-level internal echoes; 2) non-mobile diffuse, low-level internal echoes; 3) fluid-debris level; 4) thin internal
septations; 5) thick internal septations; 6) sponge-like cluster of cysts; 7) concave thick wall and 8) convex thick wall
(mural nodule).
8. ) Solid Nodules
It has generally been accepted that B-mode ultrasound cannot distinguish benign from solid breast nodules with
enough accuracy to avoid biopsy. In the past, therefore, when BUS has demonstrated a solid nodule, biopsy has
always been recommended. Because of this perceived inability of the B-mode image to differentiate benign solid from
malignant, other sonographic findings have been investigated. Doppler has been used to try to demonstrate malig-
nant neovascularity in the hope that lack of demonstrable neovascularity would obviate the need for biopsy. Unfortu-
nately, the sensitivity of Doppler has also been too low to prevent biopsy.
We have recently reassessed the ability of the B-mode BUS image to characterize solid nodules. Each solid
nodule was evaluated for several sonographic criteria. We derived criteria from a combination of literature reports and
our own retrospective nonpublished joint study with Swedish Medical Institute in Denver, Colorado, comprised of 400
solid nodules which had undergone excisional biopsy. Based on the retrospective study we selected individual
sonographic criteria which had a less than a 5% chance of being associated with malignancy as probably benign.
Individual findings which had between 5% and 49% as being indeterminate and findings which had a 50% or greater
association with malignancy were classified as probably malignant.
9. ) Malignant Characteristics in Solid Noduies
For malignant characteristics the sensitivities, positive predictive values and relative risks are listed in the follow-
ing table. The pre-test probability or prevalence of disease was 18.1%. The adjusted risk is the positive predictive
value divided by the prevalence.
CHARACTERISTIC
SENSITIVITY
PPV
RELATIVE RISK
Spiculated capsule
38.9
94.9
5.24
Taller-than-wide
40.0
88.1
4.87
Branch pattern
27.4
76.5
4.23
Angular margins
86.3
74.5
4.12
Markedly hypoechoic
69.5
66.0
3.65
Shadowing
50.5
65.8
3.64
Duct Extension
23.2
64.7
3.57
Calcification
27.8
62.5
3.45
Microlobulation
73.7
53.0
2.93
Many of the sonographic findings of malignancy (spiculation, angular margins, calcification, microlobulation, duct
extension) are similar to the mammographic findings and require no further explanation.
Volume 93, Number 4 - September 1996
207
10.) Benign Characteristics in Solid Nodules
For benign characteristics the specificity, negative predictive values, and relative risks are listed in the following
table. The prevalence of cancer in this population of solid nodules is 18.1%.
CHARACTERISTIC
SPECIFICITY
SENSITIVITY
NPV
RELATIVE RISK
Hyperechoic
5.6%
100.0%
100.0%
0.000
Ellipsoid shape
54.3%
98.9%
99.6%
0.002
3 or fewer lobulations
21.1%
98.9%
98.9%
0.060
thin echogenic capsule
81.7%
94.7%
98.6%
0.080
Purely hyperechoic structures represent normal fibroglandular elements within the breast. Although this is prob-
ably the commonest cause of palpable abnormalities, is also a common cause of asymmetric mammographic densi-
ties, and is an occasional cause of discrete mammographic nodules, only a small percentage of these are biopsied
(accounting for the low 5.6% specificity). The BUS is usually interpreted as normal. Nevertheless, some are biopsied
at the surgeon’s or patient’s insistence. We have never seen a purely hyperechoic breast cancer, although many
cancers have thick echogenic rims which represent fibroelastotic host reaction to the tumor. In this series all of the
small number of “fibrous pseudotumors’’ were benign. (100% NPV)
The classical fibroadenoma is well-circumscribed and perfectly smoothly ellipsoid in shape with a horizontal
diameter greater than the AP dimension (wider than tall). Most small fibroadenomas under 1.0 cm in maximum
diameter are in this category. Unfortunately, as fibroadenomata enlarge, they have a tendency to become multilobulated
and more irregular in shape. Nevertheless, over 50% of the benign nodules in this series were ellipsoid in shape.
When a well-circumscribed ellipsoid nodule Is demonstrated, there is less that a 1% chance of malignancy (NPV = 98.9%).
Some benign solid nodules have 2 or 3 smooth, gentle lobulations, and similar to mammographic findings, such
nodules have a very high likelihood of being benign. Nodules which have more than 3 lobulations frequently merely
represent larger fibroadenomata, but the odds of malignancy shift just enough that nodules with more than 3 lobula-
tions must be considered indeterminate (NPV only 92.3%). These nodules, like the ellipsoid nodules described above
must be well-circumscribed and wider in the transverse dimensions than in the AP dimension.
A thin echogenic pseudocapsule around a solid nodule suggests a pushing, non-invasive leading edge, a
non-malignant finding. 81 .7% of the biopsy-proven benign solid nodules had a thin echogenic capsule. Only 1 .4% of
malignant nodules had a thin echogenic capsule. Previous studies have evaluated well-circumscribed margins of the
nodule as a benign characteristic and found it insufficiently accurate to avoid biopsy. We believe that a thin echogenic
capsule represents a more specific form of well-circumscribed. The well-circumscribed outer margin of the nodule
represents the well-circumscribed inner border of the pseudocapsule. With a thin echogenic capsule, however, not
only is the inner border of the capsule well-circumscribed, but the outer border is also well circumscribed. This gives
us more useful information about the aggressiveness of the nodule.
Because previous studies and even our own retrospective study found that well circumscribed nodules were
occasionally malignant, we chose to require a combination of shape plus a thin echogenic capsule in order to classify
a nodule as probably benign (unless it was purely hyperechoic). Combinations of findings which could lead to prob-
ably benign classification were, therefore: 1) a well-circumscribed purely hyperechoic structure; 2) a thinly encapsu-
lated perfectly ellipsoid solid nodule, and 3) a thinly encapsulated, well-circumscribed solid nodule with 3 or fewer
smooth, gentle lobulations.
Using this combination of findings we were able to classify over half of all the nodules we evaluated and 70% of
all solid nodules as probably benign. The results of the overall nodule classification are as follows:
CLASSIFICATION
NUMBER (%) OF
NUMBER (%) OF
NODULES
MALIGNANT NODULES
Probably benign
302 (57.4%)
1 (00.3%)
Indeterminate
120 (22.8%)
15 (12.5%)
Probably malignant
104(19.8%)
79 (76.0%)
In the entire group of 526 solid nodules 95 (18.1%) were malignant. This represents the prevalence of malig-
nancy in this group of solid nodules. Only 0.3% of solid nodules classified as probably benign were malignant. The
negative predictive value in this group was 99.7%. The adjusted risk of a probably benign Classification is a dramati-
zes
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
cally reduced .017. Of nodules classified as indeterminate 12.5% were malignant. Of lesions classified as probably
malignant 76.0% were malignant. Clearly the risk of malignancy in the probably malignant and indeterminate catego-
ries was high enough to justify continued biopsy of all solid nodules with such classifications. In the "probably benign”
category, however, the negative-to-positive biopsy ratio of 301-to-one is so high that the need for biopsy of such
nodules has to be strongly questioned if these results are reproducible by others.
We cannot recommend that others immediately base the decision to biopsy or not biopsy solid nodules strictly
upon sonographic criteria, especially if they do not have high quality equipment optimized for near-field imaging. We
have performed many BUS examinations over several years and have correlated most of these with pathology
reports. Individual centers should probably initially only internally classify solid nodules without officially reporting
these classifications until enough pathological correlations are available to assess the efficacy of sonography in
characterizing solid nodules in their own hands. During this interval, additional experience, confidence, and a feel for
the technical and equipment demands of BUS will be gained. It should be expected that initially a smaller percentage
of nodules will be classifiable as probably benign than we are reporting. With time this percentage should increase.
The algorithm we recommend should be strictly followed: First look for malignant findings. A single malignant finding
requires a classification of probably malignant. Only if no malignant findings are found should benign characteristics
be sought. If strict criteria for benignancy are not found, the nodule must be classified as indeterminate. If there is
even the slightest question about any characteristic, the nodule should at least be characterized as indeterminate and
biopsy should be performed. Only when very strict criteria for benignancy are met should a nodule be classified as
probably benign.
In summary, BUS is useful not only in determining cystic vs. solid, but in further characterizing both cystic and
solid nodules. BUS is better at distinguishing benign from malignant than has been previously reported. Aggressive
diagnostic BUS with top-of-the-line equipment can prevent unnecessary biopsy when simple cysts, some types of
complex cysts, and fibroglandular tissues are the cause of clinical or mammographic abnormalities. In the future BUS
may be able to prevent unnecessary biopsy of some solid nodules.
Author: N. Karol Anderson is a Senior Medical Student at UAMS.
Author/Editor: David Marshfield, M.D., is Director of Radiology at Riverside Imaging Center and Clinical Associate Professor of
Radiology at UAMS.
Volume 93, Number 4 - September 1996
209
I-
I!:.
't'i
\
3
:>
iir
Practice Update ‘96
for Primary Care Physicians
Saturday, October 19, 1996
Cityplace, Dallas
Course Director
Clare McCluggage, M.D.
Topics: Acute Ml, CHF, Anxiety Syndrome,
Dementia, STDs, Prenatal Care,
Antibiotics for Pediatrics and Adults
For more information, please call the CME Office at
St. Paul Medical Center in Dallas at 214/879-2292
PHYSICIAN
Part Time
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now hiring a Licensed Physician for
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or call:
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Attention Sam Kelley
COULD YOU USE AN EXTRA $10,000?
The Army Reserve will pay you a yearly sti-
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orthopedic surgery, neurosurgery, urology,
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Once you complete your residency you
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In Memoriam
Joe C. Parker, M.D.
Dr. Joe C. Parker of Springdale, died Tuesday, July
30, 1996. He was 73. He is survived by his wife, Ival
Parker; a son. Lane (Andy) Parker, Hollywood, Calif.;
a daughter, Louise Newcomb, Little Rock; two broth-
ers, Douglas W. Parker, Fort Smith, and Roy A. Parker,
Pismo Beach, Calif., and a sister, Harriet Jane Parker,
Mountain View.
Vance M. Strange, M.D.
Dr. Vance M. Strange of Stamps, died Friday, July
26, 1996. He was 87. He was preceded in death by a
son, Bruce Strange, on June 15, 1996. He is survived
by his wife, Lydia Strange; two sons, Vance M. Strange,
Jr. and Stephen L. Strange, both of Conway; one
daughter, Deborah Ward of Tucson, Arizona; nine
grandchildren, and one great-granddaughter.
Walton R. Warford, M.D.
Dr. Walton R. Warford of North Little Rock, died
Monday, July 15, 1996. He was 77. He is survived by
his wife. Sue Watson Warford; a son, Walton R. Warford
Jr., Fayetteville; a sister. Dr. Frances Elmer, Hunts-
ville, Texas; two grandchildren, Walton Robert Warford
III and Sarah Katherine Warford.
Volume 93, Number 4 - September 1996
Things To Come
ARKANSAS LOCATION
October 4
Psychiatry for the Primary Care Physician. Clarion
Hotel (Intersection of Hwy. 62 and Hwy. 71 bypass),
Fayetteville, Arkansas. 12:00 noon to 5 p.m. Sponsored
by Washington Regional Medical Center. This confer-
ence has been planned in conjunction with the Arkan-
sas Razorback and Florida football game scheduled for
Saturday, October 5. There are limited hotel rooms
and football tickets available. For more information,
call (501) 442-1823.
October 5-6
Lymphomas and Leukemia: Clinical Advances,
Basic Science and Supportive Care Issues. J. Bennett
Johnston Building, Tulane University Medical Center,
New Orleans, LA. Sponsored by Tulane University
Medical Center, Tulane Cancer Center, Center for Con-
tinuing Education and Nursing Resource Center. For
more information, call (504) 588-5466 or 1-800-588-5300.
October 9-13
Infectious Disease '96 Board Review Course - A
Comprehensive Review for Board Preparation. The
Hyatt Regency Hotel, Washington, D.C. Sponsored
by the Center for Bio-Medical Communication. For
more information, call (201) 385-8080.
October 10 - 11
22nd Annual Symposium on Obstetrics & Gyne-
cology. Eric P. Newman Education Center, Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Department of Obstetrics and Gy-
necology and the Office of Continuing Medical Edu-
cation at Washington University School of Medicine,
St. Louis. For more information, call (800) 325-9862.
October 17 - 19
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
ARKANSAS LOCATION
October 25 and 26
Breast and Cervical Cancer Screening and Diag-
nosis. UAMS Campus, Little Rock. Interactive video
site available statewide. CME hours available. For more
information, call Dianne Crippen, R.N., Arkansas De-
partment of Health, at (501) 661-2636.
November 1-3
New Developments in the Pathogenesis & Treat-
ment of NIDDM (non-insulin dependent diabetes
mellitus). Radisson Resort, Scottsdale, Arizona. Spon-
sored by the American Diabetes Association of Ari-
zona and the National Institute of Diabetes and Di-
gestive and Kidney Diseases. For more information,
call (602) 995-1515.
November 14 - 17
15th Annual Scientific Meeting - Pain and Dis-
ease: Causes, Consequences, and Solutions. Sheraton
Washington Hotel, Washington, DC. Sponsored by the
the American Pain Society. For more information, call
(847) 375-4715.
November 20 - 24
90th Annual Scientific Assembly - Yesterday's
Caring with Today's Technology. Baltimore Conven-
tion Center, Baltimore, Maryland. Sponsored by the
Southern Medical Association. For more information,
call (800) 423-4992 or (205) 945-1840.
December 7
Cardiology Seminar. Washington University Medi-
cal Center, St. Louis, Missouri. Sponsored by the Of-
fice of Continuing Medical Education, Washington Uni-
versity School of Medicine. For more information, call
1-800-325-9862.
212 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Keeping Up
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category I of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Spine Center Conference, 1st Wednesday, 7:00 a.m.. Southwestern Bell/Arkla Room. Light Breakfast provided.
Urology Grand Rounds, September 17th and November 5th, 5:30 p.m.. Southwestern Bell/Arkla Room, Refreshments provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
As an organization accredited for continuing medical education by the Accreditation Council for Continuing Medical Education, the
University of Arkansas for Medical Sciences certifies the following continuing medical education activities meet the criteria for Category I
of the Physician's Recognition Award of the American Medical Association.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Paculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Volume 93, Number 4 - September 1996
213
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GURadiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology &f Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS Hospital
OB/GYN Fetal Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology/ Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
214
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Thursdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroradiology Conference, 3rd Friday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics! Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Gynecologic Malignancies, 3rd Thursday every other month, 7:00 a.m., various area hospitals
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month at
Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 4 - September 1996
215
Advertisers Index
Advertising Agencies in italics
Information for Authors
AMS Benefits 166
Arkansas Blue Cross & Blue Shield 174
Arkansas Children's Hospital inside back
Autoflex Leasing inside front
Care Network 197
The Alan Rothman Company, Inc.
Consumer Quote USA 170
Freemyer Collection System 174
The Medical Protective Company 194
Williams Marketing Services
The Paul Revere Life Insurance Company 190
Riverside Motors, Inc 172
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory back cover
Strategic Marketing
State Volunteer Mutual Insurance Company 162
The Maryland Group
Southwest Capital Management 165
Marion Kahn Communications, Inc.
U.S. Air Force 180
BJK&E Specialized Advertising
U.S. Air Force Reserve 161
HMS Partners, Inc.
U.S. Army Active 187
Young & Rubicam, Inc.
U.S. Army Reserve 210
Young & Rubicam, Inc.
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' THE Journal
OF THE Arkansas
MEDICAL SOCIETY
Volume 93 Number 5
October 1996
HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND. AT
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Words we still live by at State Volunteer Mutual (SVMIC): Asa
physician owned and operated liability insurance provider, we . _
have a compelling interest in the continuing education of doctors.
Every year, SVMIC conducts scores of Loss Prevention Seminars
to help impart the knowledge physicians need to face the ever
growing challenge of malpractice litigation. In addition, we
provide professional liability insurance at net cost, and we
never settle a case without the doctor's permission. SVMIC -
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE PRESIDENT
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
OhstetricsIGynecology
Internal Medicine
Surgery
Family Practice
UAMS
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
Volume 93 Number 5 October 1996
CONTENTS
FEATURES
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
220 How Much?
Editorial
Samuel E. Landrum, M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
222 Medicine in the News
Health Care Access Foundation Update
Zinc Lozenges for the Common Cold
Ipratropium Bromide for Runny Noses
Interpretation of Mammography Requires more than X-ray Report
Disciplinary Action Bulletin - Arkansas State Medical Board
229 New Member Profile
Suzanne W. Yee, M.D.
231 Gastrointestinal Endoscopy Privileges in Arkansas -
A Hospital Survey
Special Article
Geoffrey Goldsmith, M.D.
235 Post Cesarean Section Death
Loss Prevention
J. Kelley Avery, M.D.
245 HIV/AIDS Surveillance Program - Conducting Follow-up
Investigations of Cases with No Identified Risk
Jan Bunch
255 Arkansas Medical Society Alliance News
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information: Contact Tina G. Wade, The
journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
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Articles and advertisements published in The journal
are for the interest of its readers and do not represent
the official position or endorsement of The journal or the
Arkansas Medical Society. The journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1996 by the Arkansas Medical Society.
DEPARTMENTS
227 AMS Newsmakers
237 Cardiology Commentary & Update
240 State Health Watch
246 Arkansas HIV/AIDS Report
248 Outdoor MD
251 New Members
257 Radiological Case of the Month
259 In Memoriam/Resolutions
260 Things to Come
260 Keeping Up
Cover photograph of Petit Jean State Park taken by Tim Schick of the Arkansas Department of Parks
& Tourism.
Editorial
How Much?
Samuel E. Landrum, M.D., F.A.C.S.’^
It is usually cheaper to die than live. The ideal
that living is expected to have substantial costs is part
of our common cultural makeup. We rarely have con-
sidered how much should be spent individually or by
shared pooling of resources for combating sickness or
preserving health until recently. Just think of how of-
ten communities willingly have fund raisers for major
treatments of one of their own or to get a new ambu-
lance, fire truck or similar equipment for their mutual
use. We may have known the cost or fee for individual
operations or therapies, but consideration of the ex-
pense for prevention of diseases or lessening the mor-
bidity of a disease has not been an emphasis before
the current major changes of providing health care.
The relationship of cost to usual benefit is being stud-
ied and reported frequently lately.
Colorectal cancer is the second most frequent can-
cer in this country and cure by resection is possible in
the early stages of primary disease. Isolated metastases
are best treated with resection yielding reported 25-
33% survival for five years in good centers. Thus we
commonly are conducting rather extensive searches
for early signs of recurrence or a metastasis. Annual
colonoscopy, blood counts, chemistry screens and
more frequent CEA levels are now being challenged
as too aggressive. Especially after two years without
evidence of new disease, screening is recommended
only at much less frequent intervals such as two, three
or five years. The interval between detailed evalua-
tions increases as the patient continues to survive with-
out disease. This does not countermand the need to
attend to clinical symptoms that may arise before the
scheduled comprehensive examinations.
Detection of metastatic colorectal cancers was stud-
ied for 22,715 patients from the files of Veterans Af-
fairs Hospitals during a recent seven-year period in
which 12,150 developed metastatic disease. Data for
the cost of surveillance were calculated and the years
of added life gained by resecting metastatic lesions were
contrasted with those of patients who did not have
such treatment. The cost of surveillance for each year
of life gained by treatment was found to be $203,000.
* Dr. Landrum is affiliated with Holt-Krock Clinic in Fort Smith
and is a member of the editorial board for The Journal of the
Arkansas Medical Society.
This did not include special studies, transportation or
other expenses pertaining to the case. The authors
remark about this high cost, but they give interesting
information about other commonly applied preventive
strategies in medicine. For instance, the cost of each
year of life gained by screening the elderly for cervical
cancer is $2900; propanolol for hypertension is $11,000;
bone marrow transplantation for leukemia is $62,500;
ICU interventions for hematologic malignancies is
$189,339; and ICU care for AIDS patients with
Pneumocystis carinii pnemonia with respiratory fail-
ure is $200,000 to $300,000. The article also included
that the cost per year of life gained by taking
cholestyramine to control elevated cholesterol is
$117,400. Patients continually impress me about how
anxious they are to know about their cholesterol, and
apparently are willing to spend (a good bit of money)
to reduce it.
There was a recent report from Europe to the ef-
fect that follow-up of patients treated for colorectal
cancer did not yield but a two percent better overall
survival than simply dismissing patients after resec-
tion to return if they had any trouble. One should
look at such reports for the fine print before adhering
to a less stringent protocol. However, it is demon-
strable for breast cancer as well that getting every test
that may be remotely abnormal every few months is
not beneficial according to a multi-center study in
Europe.
Fear of breast cancer is said to be the most horrify-
ing one for a woman. I believe that screening
mammograms annually are very important for women
from forty to fifty years old. Data support this practice
based on the more rapid growth of tumors in younger
breasts and the better results of treatment of lesions
detected smaller than one centimeter. The argument
has been made that the cost is prohibitive to recom-
mend annual mammography for the younger group
of women because the incidence of breast cancer is
higher beyond the age of fifty. The marginal cost per
year of life saved by annual screening mammograms
has been found to be $25,600 for women aged 50-79,
but it increases only to $27,100 if annual screening is
done for those 40-49 as well. Since it seems that breast
cancer enlarges slower in post-menopausal patients.
220
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
T
the most cost-effective strategy was found to be for
annual mammograms from 40-49 and mammograms
every two years after fifty years old with a life time
costs of $20,200 per year of life saved. From a societal
view, this latter strategy seems to be good to me. The
younger women often still have family rearing con-
cerns and the death of younger persons is viewed as
more tragic than that of older ones.
Wouldn't it be great if government spending was
reduced as medical spending seems to be - based on
the benefit per cost? Regulations have only lately been
considered in this light; it seemed that anything
thought to be good was to be done regardless of cost.
A "trihalomethane drinking-water standard" of 1979
incites a cost of $200,000 estimated for each life saved.
Contrasted are the 1990 restrictions on wood-preserv-
ing chemicals that impose an estimated cost of $6.3
trillion per life saved. A study of 33 safety laws by Kip
Viscusi of Duke University found only 13 saved lives
at a cost of less than $4,000,000 each which was the
highest he thought reasonable. Transport regulators
accept rules that save lives at $3,000,000 each. Envi-
ronmental rules are accepted at higher costs.
It is impossible to set a monetary value on a life
intrinsically or probably extrinsically. Who would not
spend all they could to recover a kidnapped child or
secure a costly cure for a sick family member? How-
ever, we can alter patterns of practice without harm-
ing anyone's health by watching for more information
along the lines mentioned above and seeing that our
patients do get the best for their expenditures.
References
1. Wade, Terence R, K.S. Virgo, Marcia J. Li, P.W. Callander,
Walter E. Longo, and Frank E. Johnson. Outcomes after
detection of metastatic carcinoma of colon and rectum. JL of
the Amer. Coll. Of Surg. 1996, 182: 353-361.
2. Lindfors, Karen K. and C. John Rosenquist. The cost-
effectiveness of mammographic screening strategies. JAMA
1995, 274: 881-884.
3. The Economist. July 26, 1996.
4. Tompkins, Ronald K. Preserving our integrity. Arch. Surg.
1996, 131: 801-806.
CORRECTION NOTICE:
Regarding the Special Article titled
"Breastfeeding in Arkansas: Trends in the North-
east Region and Physician Self Assessment Quiz"
in last month's issue - the sentence which reads
"Of those with augmentation, none were able to
breastfeed successfully" should read "Of those
with augmentation, nine were able to breastfeed
successfully." This sentence is in the fifth para-
graph under the Methods and Findings heading
of the article.
Some simple logic. . .
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it be
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Medicine in the News
Health Care Access Foundation
As of September 1, 1996, the Arkansas Health Care
Access Foundation has provided free medical service
to 11,504 medically indigent persons, received 21,644
applications and enrolled 42,284 persons. This program
has 1,737 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
Zinc Lozenges for the Common Cold
Common colds are ubiquitous afflictions with few
effective therapies. Zinc has been shown to have anti-
viral effects and to induce interferon, and some prior
studies have suggested it may be useful in the com-
mon cold. This randomized trial assessed whether zinc
gluconate lozenges could reduce the duration of cold
symptoms.
Researchers randomized 100 employees of the
Cleveland Clinic who had cold symptoms for less than
24 hours to receive zinc lozenges (13.3 mg of zinc ev-
ery two hours while awake) or matching placebo (con-
taining calcium lactate pentahydrate) for as long as
they had symptoms.
Patients taking zinc lozenges had a complete reso-
lution of symptoms significantly sooner than placebo
recipients (median, 4.4 vs. 7.6 days), and they had
fewer days of coughing, headache, hoarseness, nasal
congestion and drainage, and sore throat. However,
the groups did not differ significantly in the resolu-
tion of fever, muscle ache, scratchy throat, or sneez-
ing. Side effects such as nausea and a bad taste were
significantly more common with zinc than placebo.
Comment: The duration of common cold symp-
toms can be reduced with zinc lozenges. Whether the
potential adverse effects of the lozenges are worth the
benefit is a decision best left to individual patients. -
CD Mulrow
Mossad SB; et al. Zinc gluconate lozenges for treating
the common cold; a randomized, placebo-controlled study.
Ann Intern Med 1996 Jul 15; 125:81-8.
Reprinted by permission of Journal Watch, Volume
16, Number 16, August 15, 1996 issue. Copyright 1996.
Massachusetts Medical Society.
Ipratropium Bromide for Runny Noses
Some typical symptoms of the common cold are
rhinorrhea, nasal congestion, and sneezing, which are
mediated in part by cholinergic mechanisms. This
multicenter, randomized trial shows that intranasal
ipratropium bromide, an anticholinergic agent, may
222
be a useful alleviator of these symptoms.
The study included 411 people who had rhinor-
rhea of at least moderate severity, nasal discharge of
at least 1.5 grams over a one-hour period, and symp-
toms that had lasted less than 36 hours. Subjects were
randomized to ipratropium bromide nasal spray
(0.06%) given in two 42- wg sprays per nostril three to
four times daily for four days, placebo nasal spray given
in the same manner, or no treatment.
Ipratropium reduced subjective and objective
symptoms of rhinorrhea compared with both the pla-
cebo and nontreatment groups. Sneezing, but not na-
sal congestion, was also reduced with ipratropium.
Patients rated the overall effectiveness of treatment as
more favorable with ipratropium than with placebo or
no treatment, even though adverse effects such as
blood-tinged mucus and nasal dryness were more com-
mon with ipratropium.
Comment: Intranasal ipratropium can be added to
the armamentarium of common cold treatments. Its
efficacy, cost, and adverse effects compared with other
treatments (such as the zinc lozenges discussed above)
are not known. - CD Mulrow
Hayden FG; et al. Effectiveness and safety of intranasal
ipratropium bromide in common colds: a randomized, double-
blind, placebo-controlled trial. Ann Intern Med 1996 Jul
15, 125:89-97.
Reprinted by permission of Journal Watch, Volume
16, Number 16, August 15, 1996 issue. Copyright 1996.
Massachusetts Medical Society.
Interpretation of Mammography Requires
More than X-ray Report
A two-part study of mammography proves the
maxim that no test result should be interpreted in iso-
lation of clinical data.
The researchers first studied 28,271 California
women who had a first screening mammogram be-
tween 1985 and 1992, of who 238 were found to have
breast cancer during the next one to two years. Allow-
ing 13 months for detection of breast cancer, the sen-
sitivity of the screening mammogram was 90% over-
all, ranging from 77% among women aged 30 to 39 to
more than 91% for women over 50. When analysis was
restricted to invasive cancers (excluding ductal carci-
noma in situ), sensitivities were 58%, 75%, 92%, 93%,
and 87%, respectively, for women in their thirties, for-
ties, fifties, sixties, and older. Sensitivity was only 69%
among women under 50 with a family history of breast
cancer, possibly because of faster-growing tumors.
Notably, 59% of younger women who later presented
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Pledging commitment is one of the most important
things that human beings can do for one another. It
means I’ll do only my best for you. I'll fight for your
rights. I'll be there for you.
At Snell Laboratory we make that type of commitment to
each of our patients. We dedicate ourselves to making
them as comfortable and as mobile as possible. We give
them back as much of their former life as we can.
A Match Made In Heaven.
Our computer-aided design and manufacture
(CADjCAM) system makes so much more possible in
creating custom-fit prostheses than ever before. And
new lightweight, space age materials mean more
for our patients with custom orthoses.
So regardless of what responsibilities your
patients agree to in life, from going out to play to
attending a special occasion, our commitment
to comfort never waivers.
Snell Prosthetic and Orthotic Laboratory has
been in business since 1911. We've said "I do" to
our patients since day one.
Prosthetic & Orthotic
Laboratory
THE LATEST IN TECHNOLOGY. THE BEST IN CARE.
Offices in Little Rock, Fort Smith, Russellville, Mountain Home, Fayetteville, and Hot Springs.
Little Rock (501) 664-2624 • Statewide Toll-free 1-800-342-5541
with breast cancer did so within 13 months, versus
only 39% of older women.
The second paper incorporates specificity data and
offers guidelines for interpreting abnormal
mammograms. Because the risk of breast cancer in-
creases with age, the probability of breast cancer in a
woman whose first mammogram is read as "additional
evaluation needed" (as were 93% of abnormal
mammograms in this study) is only about 1% for
women in their thirties, increasing to 7% for those over
age 70.
Comment: These analyses suggest that clinicians
should neither be overly reassured by negative
mammograms among young women, nor overly
alarmed by marginally abnormal results, since the test's
diagnostic performance is weak in this population. In
older patients, however, both positive and negative
test results are more likely to be accurate. - TH Lee
Kerlikoivske K; et al. Effect of age, breast density, and
family history on the sensitivity of first screefling mammog-
raphy. JAMA 1996 Jul 3; 276:33-8.
Kerlikowske K; et al. Likelihood ratios for modern screen-
ing mammography; risk of breast cancer based on age and
mammographic interpretation. JAMA 1996 Jul 3; 276:39-43.
Reprinted by permission of Journal Watch, Volume
16, Number 16, August 15, 1996 issue. Copyright 1996.
Massachusetts Medical Society.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board officer should be contacted. There-
fore, we routinely suggest this list be shared with the
appropriate supervisory personnel and recruiters in
your agency.
At the completion of the disciplinary period, the
nurse applies for reinstatement. Reinstatement is con-
tingent upon meeting the conditions set forth by the
Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY:
August 14, 1996
’^Meredith Chisholm Atkinson, RN 23138 (Siloam
Springs) Suspension, 18 months; Civil penalty, $6,500
^Evelyn Dinease Cleaves, LPN 32716 (Jonesboro) Sus-
224
pension, 2 years; Civil penalty, $2,500
August 15, 1996
*Paula Ann Davis Marlar Davis, RN 14369 (Crossett)
Probation, 2 years; Civil penalty, $500
'^Pamela Jean Strawn Andrews, LPN 12528 (Little Rock)
Probation, 30 months; Civil penalty, $1,000
August 16, 1996
“^Michael Chavis, RN 26818 (Little Rock) REVOKED
“^Morgyn Meleia Cloud Rector, LPN 24860 (Little Rock)
Probation, 2 years; Civil penalty, $250
CONSENT AGREEMENT
"^Eva Marie Edmund, RN 43038 (Little Rock)
’*'Mary Carolyn Morse Wesson RN 43780/CRNA C-875
(DeQueen)
*Anne Michelle Bailey Hollister, RN 27555/RNP P-555
(Little Rock)
OFE PROBATION
’^Audrey Orsby, LPN 20682 (Cherry Valley) 7/1/96
*Lynda Lou Young Osborn, LPN 16935 (Nashville) 8/1/96
VOLUNTARY SURRENDER
*Hollie Michelle Schmieder Heffington, LPN 32046
(White Hall) 6/30/96
“^Joe Burley Rambo, II, LPN, 31411 (Wilmar) 8/6/96
’^Lisa Anne Sullivan Hamilton Billiot Julian Hicks, RN
24568 (Little Rock/Ed Dorado) 8/15/96
LETTER OE REPRIMMAND
“^Betty Lou Arnold, RN 9486 (Camden) 8/12/96
If you have employed the following nurses or have
any knowledge of their whereabouts, please notify the
board of nursing:
“^Jacob Kent Davis, LPTN 1650
^Jackie Lynn McKenzie Sullinger, LPN 34137
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
J
United Services Life Insurance Company
A ReliaStar Company
4601 Fairfax Drive P.O. Box 3700 Arlington, VA 22203
Introduces °
AFFORDABLE LIFE INSURANCE
The Best Idea For . . . Personal Insurance - Business Insurance - Mortgage Protection
Copyright 1/90 Alt Rights Reserved
MONTHLY RATES
NON-SMOKER RATES
MONTHLY RATES
ISSUE
AGE
$100,000
Male Female
$250,000
Male Female
$500,000
Male Female
$1,000,000
Male Female
43
13.17
12.84
26.67
25.84
49.17
47.50
94.17
90.84
44
13.25
12.92
26.88
26.05
49.59
47.92
95.00
91.67
45
13.34
13.00
27.09
26.25
50.00
48.34
95.84
92.50
46
13.75
13.09
28.13
26.46
52.09
48.75
100.00
93.34
47
14.59
13.17
30.21
26.67
56.25
49.17
108.34
94.17
48
15.42
13.25
32.30
26.88
60.42
49.59
116.67
95.00
49
16.25
13.34
34.38
27.09
64.59
50.00
125.00
95.84
50
17.09
13.75
36.46
28.13
68.75
52.09
133.34
100.00
51
17.92
14.59
38.55
30.21
72.92
56.25
141.67
108.34
52
18.75
15.42
40.63
32.30
77.09
60.42
150.00
116.67
53
20.00
16.25
43.75
34.38
83.34
64.59
162.50
125.00
54
21.25
17.09
46.88
36.46
89.59
68.75
175.00
133.34
55
22.92
17.92
51.05
38.55
97.92
72.92
191.67
141.67
56
24.59
18.75
55.21
40.63
106.25
77.09
208.34
150.00
57
26.25
20.00
59.38
43.75
114.59
83.34
225.00
162.50
58
27.92
21.25
63.55
46.88
122.92
89.59
241.67
175.00
59
30.00
22.92
68.75
51.05
133.34
97.92
262.50
191.67
60
40.00
24.59
93.75
55.21
183.34
106.25
362.50
208.34
61
42.09
26.25
98,96
59.38
193.75
114,59
383.34
225.00
62
44.17
27.92
104.17
63.55
204.17
122.92
404.17
241.67
63
46.67
30.00
110.42
68.75
216.67
133.34
429.17
262.50
64
49.17
40.00
116.67
93.75
229.17
183.34
454.17
362.50
65
52.09
42.09
123.96
98.96
243.75
193.75
483.34
383.33
ISSUE
AGE
$100,000
Male Female
$250,000
Male Female
$500,000
Male Female
$1,000,000
Male Female
20
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
21
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
22
12.50
12.50
25.00
25.00
45,84
45.84
87.50
87.50
23
12.50
12.50
25.00
25.00
45.84
45,84
87.50
87.50
24
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
25
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
26
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
27
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
28
12.50
12.50
25.00
25.00
45,84
45.84
87.50
87.50
29
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
30
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
31
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
32
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
33
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
34
12.50
12.50
25.00
25,00
45.84
45.84
87.50
87.50
35
12.50
12.50
25.00
25.00
45.84
45.84
87.50
87.50
36
12.59
12.50
25.21
25.00
46.25
45.84
88.34
87.50
37
12.67
12.50
25.42
25.00
46.67
45,84
89.17
87.50
38
12.75
12.50
25.63
25.00
47.09
45.84
90.00
87.50
39
12.84
12.50
25,84
25.00
47.50
45.84
90.84
87.50
40
12.92
12.59
26.05
25.21
47.92
46.25
91.67
88.34
41
13.00
12.67
26.25
25.42
48,34
46.67
92.50
89.17
42
13.09
12.75
26.46
25.63
48.75
47.08
93.33
90.00
Other amounts available upon request. Premiums are standard rates based on applicant's age at issuance of policy. Policies are non-cancellable as
long as premiums are paid. Premiums may be paid annually, semi-annually, and monthly bank draft only. (A no-cost medical exam may be required
depending on age, health, or amount of coverage desired). Policies are annual renewable and convertible term. Policy Form No. L-ORD-51 01 -91 , Graded
Premium, Level Death Benefit to age 84. Premiums increase annually. Underwritten by United Services Life Insurance Company, Arlington, VA 22203.
Established in 1937. Over $21 Billion Dolla,rs of Life Insurance in Force as of 12/31/95. NOT AVAILABLE IN ALL STATES.
United Services
LIFE INSURANCE COMPANY
Application Request Form
A ReliaStar Company
The information you provide wili be kept in strict confidence.
Estabiished in 1937
Over $21 Billion Doilars of
Life Insurance in Force
as of 12/31/95
Level Death Benefit to Age 84
For More Information Call:
Local: (501) 223-4084
Toll Free: 1-800-487-4084
Fax: (501) 223-4085
NAME
ADDRESS.
CITY
STATE
ZIP
DATE OF BIRTH.
AMT. OF INS. DESIRED
HOME PHONE ( )_
BENEFICIARY
□ MALE □ FEMALE
□ SMOKER □ NON-SMOKER
WORK PHONE
AGE
The best time to call me is:
□ Morning □ Afternoon □ Evening ( □ Home □ Work
I wish to pay my premiums: □ Annually □ Semi-Annually □ Monthly Bank Draft
ADDITIONAL APPLICATION REQUESTED FOR:
NAME
DATE OF BIRTH
AMT. OF INS. DESIRED
Comments:
□ MALE □ FEMALE
□ SMOKER □ NON-SMOKER
□ I wish to cover my children
VM2-053-YRT
Are You Paying too much
%for Your Term Insurance?
For More Information Call Local: (501) 223-4084
For Priority Service — Fax: (501) 223-4085
Toll Free: 1-800-487-4084
MONTHLY RATES
SMOKER RATES
MONTHLY RATES
ISSUE
AGE
$100,000
Male Female
$250,000
Male Female
$500,000
Male Female
$1,000,000
Male Female
20
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
21
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
22
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
23
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
24
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
25
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
26
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
27
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
28
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
29
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
30
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
31
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
32
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
33
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
34
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
35
16.67
16.67
35.42
35.42
66.67
66.67
129.17
129.17
36
17.50
16.67
37.50
35.42
70.84
66.67
137.50
129.17
37
18.75
16.67
40.63
35.42
77.09
66.67
150.00
129.17
38
20.00
16.67
43.75
35.42
83.34
66.67
162.50
129.17
39
21.25
16.67
46.88
35.42
89.59
66.67
175.00
129.17
40
22.50
17.50
50.00
37.50
95.84
70.84
187.50
137.50
41
23.34
18.75
52.09
40.63
100.00
77.09
195.84
150.00
42
24.17
20.00
54.17
43.75
104.17
83.34
204.17
162.50
ISSUE
AGE
$100,000
Male Female
$250,000
Male Female
$500,000
Male Female
$1,000,000
Male Female
43
25.00
21.25
56.25
46.88
108.34
89.59
212.50
175.00
44
25.84
22.50
58.34
50.00
112.50
95.84
220.84
187.50
45
27.09
23.34
61.46
52.09
118.75
100.00
233.34
195.84
46
28.75
24.17
65.63
54.17
127.09
104.17
250.00
204.17
47
30.00
25.00
68.75
56.25
133.34
108.34
262.50
212.50
48
32.09
25.84
73.96
58.34
143.75
112.50
283.34
220.84
49
34.17
27.09
79.17
61.46
154.17
118.75
304.17
233.34
50
37.09
28.75
86.46
65.63
168.75
127.09
333.34
250.00
51
41.25
30.00
96.88
68.75
189.59
133.34
375.00
262.50
52
45.42
32.09
107.30
73.96
210.42
143.75
416.67
283.34
53
50.42
34.17
119.80
79.17
235.42
154.17
466.67
304.17
54
55.42
37.09
132.30
86.46
260.42
168.75
516.67
333.34
55
60.84
41.25
145.84
96.88
287.50
189.59
570.84
375.00
56
66.25
45.42
159.38
107.30
314.59
210.42
625.00
416.67
57
72.09
50.42
173.96
119.80
343.75
235.42
683.34
466.67
58
78.34
55.42
189.59
132.30
375.00
260.42
745.84
516.67
59
84.17
60.84
204.17
145.84
404.17
287.50
804.17
570.84
60
98.33
66.25
239.59
159.38
475.00
314.59
945.84
625.00
61
103.75
72.09
253.13
173.96
502.09
343.75
1000.00
683.34
62
109.17
78.34
266.67
189.59
529.17
375.00
1054.17
745.84
63
115.84
84.17
283.34
204.17
562.50
404.17
1120.84
804.17
64
124.59
98.34
305.21
239.59
606.25
475.00
1208.34
945.84
65
137.09
103.75
336.46
253.13
668.75
502.09
1333.34
1000.00
Other amounts available upon request. Premiums are standard rates based on applicant's age at issuance of policy. Policies are non-canceilable as
long as premiums are paid. Premiums may be paid annually, semi-annually, and monthly bank draft only. (A no-cost medical exam may be required
depending on age, health, or amount of coverage desired). Policies are annual renewable and convertible term. Policy Form No. L-ORD-51 01-91 , Graded
Premium, Level Death Benefit to age 84. Premiums increase annually. Underwritten by United Services Life Insurance Company, Arlington, VA 22203.
Established in 1937. Over $21 Billion Dollars of Life Insurance in Force as of 12/31/95. NOT AVAILABLE IN ALL STATES.
BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 2692 FT WORTH, TX
POSTAGE WILL BE PAID BY THE ADDRESSEE
THOMAS H. GEORGE
AFFORDABLE LIFE INSURANCE
P O BOX 26075
LITTLE ROCK AR 72221-9851
NO POSTAGE
NECESSARY
IF MAILED
IN THE UNITED
STATES
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1996 E-Class: Spacious interior. Stunning performance. No wonder you don’t want to be reached.
Mercedes-Benz
Riverside Motors, Inc.
1403 Rebsamen Park Rd./Little Rock, AR 72202
666-9457 & 1-800-457-6226
RP for an E300 Diesel Sedan excludes $595 transportation charge, all taxes, title/ documentary fees, registration, tags, dealer prep
ges, insurance, optional equipment, certificate of compliance or noncompliance fees, and finance charges. Prices may vary by dealer.
1 Sedan shown at MSRP of $43,500. ©1995 Authorized Mercedes-Benz Dealers
Freemyer Collection System, Inc.
1-800-694-9288
Collection Services
Electronic Claims
Remittance Posting
Physician Billing
Established 1941
Blytheville *Conway * Helena * Jonesboro * Little Rock * Paragould *West Memphis
BE AN AIR FORCE
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Today’s Air Force offers the medical envi-
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TOLL FREE 1-800-423-USAF
’i '1 iT "TT
AMS Newsmakers
Dr. Scott W.F. Carle, of Little Rock, and Dr. Steven
Collier, of Augusta, were recently certified as Medical
Review Officers for the American Association of Medi-
cal Review Officers, Inc. The organization, created in
1991, is a non-profit medical society dedicated to es-
tablishing national standards and certification of medi-
cal practitioners and other professionals in the field of
drug and alcohol testing. In their positions. Carle and
Collier will determine the validity of drug test results
and assess whether an alternative medical explana-
tion can account for a positive drug test result.
Dr. Steven P. Schoettle, a West Memphis general
surgeon, was recently appointed to a three-year term
as Crittenden Memorial Hospital's cancer liaison to the
American College of Surgeons. Dr. David Winchester,
medical director of the cancer department at the Ameri-
can College of Surgeons in Chicago, said Schoettle was
chosen because of his leadership and support of the
hospital's cancer program as well as other commis-
sion and cancer activities.
Dr. Eric Spann, a family practitioner in Green
Forest, recently completed an in-depth program aimed
at the identification and management of patients who
are victims of violent acts. The six-day conference fo-
cused on how to identify physical and sexual abuse,
how to preserve and document the evidence found
and how that evidence applies to a court of law. The
conference was funded by the Merlin Foundation's
Multidisciplinary Team and the Arkansas Commission
on Child Abuse, Domestic Violence and Rape.
The Physician's Recognition Award is awarded
each month to physicians who have completed accept-
able programs of continuing education. Recipients for
the month of August 1996 are: Debra D. Becton, Little
Rock; Charles R. Clifton, Hot Springs National Park;
William C. Furlow, Conway; Terri J. Hymel, Little Rock;
Michael B. Johnson, Little Rock; Stephen K. Magie,
Little Rock; Anne Virginia Miller, Springdale; William
V. Relyea, Cherokee Village; Ronald E. Revard,
Springdale; M. Angelo Rivero, Little Rock and
Lawrence J. Schemel, Springdale.
Dr. Scott Stinnett,
a Siloam Springs fam-
ily practitioner, was re-
cently featured in The
Herald-Leader newspa-
per for his award-win-
ning photography. He
said it's fun to win, but
he doesn't do it for that
- he does it for relax-
ation. Most recently
Stinnett won the 10*’’
Anniversary Pfizer
Labs Photo Contest,
and as a result, his
photo was placed in the
Pfizer calendar. Stinnett teaches photography in the
community education classes offered in his community.
Send your accomplishments and photo for
consideration in AMS Newsmakers to:
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
Volume 93, Number 5 - October 1996
227
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American Medical Association
Physicians dedicated to the heaith of America
New
r Profile
Suzanne W. Yee, M.D.
PROFESSIONAL INFORMATION
Specialty: Facial Plastics; Otolaryngology; Head and Neck Surgery
Years in Practice: One
Office: Little Rock
Medical School: UAMS, 1989
Intemshipl Residency: UAMS, 1990/1994
Professional affiliates! organizations: Arkansas Otolaryngology
Center, Pulaski County Medical Society, AMA, American Academy of
Otolaryngology - Head & Neck Surgery, American Academy of Facial
Plastic & Reconstructive Surgery and Associate Fellow to the American College of Surgeons
Honors! Awards: Barton Scholarship, Schlumber Award, John Whitney Award, Faculty Key, Roberts
Key, Janet M. Glasgow Award for outstanding achievement. Resident Research Award - 2nd place, AOA,
Phi Kappa Phi and Rho Chi Honor Society
PERSONAL INFORMATION
Spouse: Joe Bill Yee - a senior bank examiner with the Arkansas State Bank Department
Date!Place of Birth: July 16, 1961 in Helena, Arkansas
Hobbies: Painting T-shirts, Aerobics, Reading, Razorback Basketball and Football, Computers and Art
THOUGHTS & OTHER INFORMATION
If I had a different job, I'd be: I can't imagine doing anything else
Worst habit: procrastination
Best habit: persistence
Favorite junk food: chocolate
Behind rny back, they say: I'm a perfectionist - sometimes to the point of annoyance
I most value: my family
People who knew me in medical school, thought I was: a compulsive worrywart
The turning point of my life was when: I began caring for cancer patients and realized that I am
so very lucky and I should never feel sorry for myself.
Nobody knows I: binge on late night snacks
Favorite vacation spot: Disneyland
One goal I haven't achieved yet: having children
One goal I am proud to have reached: is being the first child in our family to obtain a college
degree in the United States
When I was a child, I wanted to grow up to be: a pharmacist
One of my pet peeves: procrastination
First job: working as a clerk at my parent's store
Worst job: working at Andy's hamburger restaurant
One word to sum me up: tenacious
My life philosophy: is to live one day at a time to the fullest
If you would like to appear in New Member
Profile or Member Profile, contact Tina Wade
at AMS at (501) 224-8967 or 1-800-542-1058.
Advanced CPT & ICD-9-CM Coding:
Beyond The Basics
Sponsored by the Arkansas Medical Society
October 30 & 31, 1996 • Riverfront Hilton - NLR
Who will benefit from this seminar?
The ADVANCED CODING PROGRAMS are advanced level classes for physicians & coding/billing staff.
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Effects, Mental Disorders, V Codes & E Codes
For more information, call the AMS office
at 1-800-542-1058 or in Little Rock 224-8967
MSoA
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230
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Special Article
Gastrointestinal Endoscopy Privileges in
Arkansas - A Hospital Survey
Geoffrey Goldsmith, M.D.,
Introduction
Credentialing primary care physicians in proce-
dures such as esophagogastroduodenoscopy (EGD)
and colonoscopy is among the more contentious is-
sues involving family physicians' privileging.’-^'’
The purpose of our study was to obtain informa-
tion on the privileging of family physicians in GI en-
doscopic procedures by hospitals in Arkansas. The
importance of such credentialing decisions is signifi-
cant since five of the state's seven family practice resi-
dencies are now teaching these procedures to their
trainees and it is likely that all of the Family Practice
residencies will do so in the future. With the expecta-
tion that many of the family practice residency gradu-
ates will be trained in Gl endoscopy, and seeking privi-
leges, requests for Gl endoscopy privileges for family
physicians will increasingly come to hospital creden-
tials committees.
Methodology
In the winter of 1994, the University of Arkansas
for Medical Sciences (UAMS), Department of Family
and Community Medicine (DFCM) mailed a survey,
with up to two telephone calls for follow up of
non-respondents, to all Arkansas hospitals in order to
ascertain whether these hospitals would provide "quali-
fied" family physicians privileges in FGD and/or
colonoscopy (referred to as GI endoscopy in this paper).
Results
Responses were obtained from 94 of the 98 hospi-
tals surveyed (95.9% response rate). Two urban and 2
rural hospitals did not respond. The first row of data
on Table 1 reveals that 54 of 94 respondents (57.5%)
grant FGD and colonoscopy privileges to "qualified"
family physicians. Forty of the hospitals do not offer
endoscopy privileges to family physicians (42.5%). As
noted on Table 1, of these 40 hospitals, 21 hospitals do
not offer endoscopy to any physicians. These hospi-
Geoffrey Goldsmith, M.D., M.P.H., is Professor and Chair-
man of the Department of Family and Community Medicine
at UAMS.
tals pointed out that no physicians asked for GI endo-
scopy privileges at their hospital. Therefore, of the 94
hospitals that responded to the survey 73 are perform-
ing GI endoscopy. Of these 73 hospitals, 74% (54/73)
provide endoscopy privileges to family physicians.
Only 19 hospitals do not provide GI endoscopy privi-
leges to qualified family physicians. An obvious ques-
tion unanswered by study is how each hospital opera-
tionally defined the criteria by which family physi-
cians can become "qualified" to perform GI endoscopy.
The UAMS DFCM surveyed eleven academic medi-
cal centers in the South Central region to ascertain
whether family physicians in the academic centers were
performing GI endoscopy (other than flexible sigmoi-
doscopy). We found that seven of the eleven family
physicians were performing GI endoscopy. Fastly, we
mapped out the practice sites of all board certified
gastroenterologists listed as practicing in Arkansas."*
According to the ABMS, official "Directory of Board
Certified Medical Specialists," in 1994 there only 52
board certified gastroenterologists practicing in Arkan-
sas - See Figure 1.“*
Discussion
While the state is about 47% rural, every gastroen-
terologist except for 6, practices in 15 of the larger towns
or metropolitan statistical areas in Arkansas (See Fig-
ure 1). Of course, this is reasonable since a gastroen-
terologist needs a certain size of population for eco-
nomic survival of the practice. In more rural commu-
nities, the family physician, general internist, general-
ist obstetrician/gynecologist, or general surgeon may
be the only physicians conveniently located and quali-
fied to provide GI endoscopy. There is less objection
by Arkansas' rural hospitals to grant family physicians
hospital privileges in GI endoscopy compared to ur-
ban, larger Arkansas hospitals. The author's informal
discussions with many family physicians reveal that if
their hospital does not grant endoscopy privileges to
qualified primary care physicians, these generalists are
likely to provide GI endoscopy in their clinical offices.
Many family physicians don't seek hospital privileges
and instead do the procedures in their offices.
Volume 93, Number 5 - October 1996
231
TABLE 1
ARKANSAS HOSPITAL SURVEY OF FAMILY PRACTICE
ENDOSCOPY PRIVILEGES
SIZE OF HOSPITAL
FP PERFORM
EGD/COFONOSCOPY
AT YOUR HOSPITAL
<100 BEDS (n = 54) >100 BEDS (n = 44)
(n) (n)
TOTAL
(n = 98)
(n)
YES
(29) (25)
57%
(54)
NO
IF PROCEDURE NOT
PERFORMED AT
HOSPITAL BY FP,
WHY NOT?
(23) (14)
43%
(40)
No FPs or any other
MD requested
these privileges
(21)
GI endoscopy privileges
refused to FPs
(19)
OF HOSPITALS
WHERE GI
ENDOSCOPY
IS PERFORMED,
PERCENTAGE THAT
PROVIDE SUCH
PRIVILEGES TO FPs
74%
(54)
*Rounding of % may result in >100% in total category
While there is no "magic" minimum number of
endoscopic procedures needed to assure competency
in basic diagnostic endoscopy, it is the opinion of some
family practice residencies and other training centers
that trainees should present to the privileges commit-
tee evidence of 25 to 100 satisfactorily completed EGD's
and 25 to 100 colonoscopies performed under direct
supervision.^"^ The training must include cognitive
training regarding indications, interpretations of diag-
nostic findings, contraindications, and management
of complications. Inclusion of a specific number of en-
doscopic procedures can ensure that there is a mini-
mum "track record" on which to base assessment of
outcomes and skills but doesn't by itself assure com-
petency. It is important to note that the American Acad-
emy of Family Physicians (AAFP) recommends against
setting a specific number of procedures before giving
privileges and emphasizes demonstrated competency
232
should be the only criterion used to judge whether a
family physician should be granted GI endoscopy privi-
leges.^
At the University of Arkansas for Medical Sciences,
the Department of Family and Community Medicine
requires that family physicians who seek credentials
for GI endoscopy have completed didactic training in
GI endoscopy and have completed at least 50 success-
ful FGD's and colonoscopies in order to be eligible for
GI endoscopy credentials without additional proctor-
ing. Most family practice residency graduates are not
trained to perform therapeutic GI endoscopic proce-
dures. Usually, a family practice residency will pro-
vide residents an opportunity to enroll in an elective
rotation of one month or more in GI endoscopy. Not
all family practice residents in a given residency pro-
gram will elect to take this additional GI endoscopy
training.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Conclusion
This study is reassuring to those family practice
residents who will be seeking GI endoscopy privileges.
First, most of the Arkansas hospitals will afford the
endoscopy trained family practice residency graduate
endoscopy privileges. Secondly, because gastroenter-
ologists are clustered in only fifteen larger communi-
ties in Arkansas, there is a strong demand for such
services throughout most Arkansas communities.
Hospital credentialing committees can use a broad
consensus of family practice training groups or the
AAFP recommendations as the basis on which to grant
family physicians GI endoscopy privileges. Further-
more, given the distribution of gastroenterologists in
our state, the availability of endoscopy in rural com-
munities will be greatly increased as graduating fam-
ily practice residents in larger number graduate from
their residencies with endoscopy skills.
Acknowledgement; The Department of Family and Com-
munity Medicine wishes to express its deep appreciation to
Kay Berry who served as the research assistant for this project.
References
1. Position Statement: On Ffospital Credentialing Standards
for Physicians Who Perform Gastrointestinal Endoscopy,
American Society of Gastrointestinal Endoscopy and the
American College of Gastroenterology, Manchester, MA and
Arlington, VA, 1993.
2. Policy on Gastrointestinal Endoscopic Training, AAFP,
Kansas City, MO, 1992.
3. Legal opinion on endoscopy. Smith, Gill, Fisher & Butts,
Kansas City, MO, July 2, 1993.
4. "The Official ABMS Directory of Board Certified Medical
Specialists", 27th Edition, 1995, Reed Reference Publishing
Co., New Providence, NJ, 1995.
5. Rodney, WM, Procedural Credentials in Pamily Medicine,
Department of Family Medicine, University of Tennessee,
Memphis, Tennessee, 1993.
6. Resident Credentialing Criteria, Department of Family
Practice, Oklahoma University, College of Medicine, 1990.
7. Cass OW, Freeman ML, Peine CJ, Zera RT, Onstad GR.
Objective evaluation of endoscopy skills during training. Ann
Intern Med, 1 18: 404, 1993.
8. Rodney WM, Hocutt JE. Jr, Coleman WH, Weber JR,
Swedberg JA, Croninc, et.al. Esophagogastroduodenoscopy
by Pamily Physicians: A Natural Multi-site Study of 717 Pro-
cedures. J Am Board Fam Pract, 3 :73-9, 1990.
9. UAMS, Family Medicine Residency Training and
Credentialing in GI Endoscopy, Little Rock, AR, 1994.
We're always looking for interesting and informa-
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that you think would be of interest to your peers,
please submit it for consideration to:
Write"
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The Journal of the Arkansas Medical Society
P.O. Box 55088
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Volume 93, Number 5 - October 1996
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Loss Prevention
Post Cesarean Section Death
J. Kelley Avery, M.D.*
Case Report
The patient was a 31-year-old mother of one who
had an uneventful pregnancy except for some slight
vaginal bleeding at 5 months gestation. The patient
was observed in the labor and delivery area of the
hospital, and the bleeding stopped spontaneously. No
subsequent bleeding occurred. Her first baby was de-
livered by cesarean section and was known to be a
normal child, now 5 years of age.
The patient came into the hospital at the expected
time of delivery in early labor. She declined an oppor-
tunity to deliver vaginally and was taken to the oper-
ating room within two hours of her admission. It was
Friday, and her regular attending obstetrician was not
on call. His associate performed an uneventful cesar-
ean section under epidural analgesia. The operative
note did not describe any intraoperative problems. The
development of the bladder flap was accomplished
easily, and the uterus was entered through a low cer-
vical incision. A healthy female infant was delivered
with Apgar scores of 9/10. The remainder of the sur-
gery proceeded without the slightest problem. The
blood loss was estimated to be 500 cc.
The surgery was completed about 4:00 p.m., and
the patient went to the floor about two hours later.
The nurse's note at 4:45 p.m. described a "soft abdo-
men with normal bowel sounds." The first night after
the surgery the patient was medicated five times for
abdominal pain.
The first day after the surgery, another one of the
associates in the group made rounds on this patient.
The patient was medicated five times for pain and one
time for "gas." The blood counts that morning were
normal, and the abdomen was said to be "soft" and
the bowel sounds "hypoactive" by the nurses. The
next day, Sunday, the same associate made rounds
and ordered "Magnesium Citrate 1/2 bottle now." The
patient had been able to walk very little because of
pain. The doctor noted the abdomen to be "distended
Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Company, Brentwood, TN.
This article appeared in the Jourml of the Tennessee Medical
Association in ftbruary 1994. It is reprinted here with permission.
but soft." Bowel sounds were described as "occasional."
The following day, Monday, the patient's regular
attending physician returned and made rounds in the
hospital. The nurse's notes during the night described
the abdomen as "distended and firm" and the bowel
sounds as "hypoactive." Again, "firm, distended and
tender" was the descriptive phrase used with refer-
ence to the abdomen. The patient had a small bowel
movement during the night and "good results" in re-
sponse to an enema at 8:00 a.m. The attending physi-
cian discharged the patient, noting that the abdomen
was "distended, soft, and the bowel sounds normal."
In the discharge summary, the attending physi-
cian recorded the abdominal pain and distention with
the comment that these complaints had responded to
"cathartics, colon tube, and enemas."
The patient was readmitted to the hospital the same
night because of "severe abdominal pain and disten-
tion." After discussion with the attending physician,
the emergency room physician began NG suction,
started IV fluids, and ordered abdominal x-rays and a
CBC/urine. The CBC was remarkable in that there were
reported 33% segmented neutrophils and 46% band
forms in the smear. The films of the abdomen showed
"a massive amount of free air in the abdomen" which
was deemed "consistent with the recent cesarean sec-
tion." The suspected diagnosis was intestinal obstruction.
The following day at 9:00 a.m. the attending phy-
sician felt that the abdomen was "distended, tender
but not tense." Through the day the patient's urinary
output was very low, and she was thought to be de-
hydrated. IV fluids were increased. A CBC was or-
dered for the night and was to be repeated the follow-
ing morning. X-rays of the abdomen were also to be
repeated in the morning. On both CBCs the band forms
were reported to be 70% and 60% respectively. Vital
signs through the night continued to show tachycar-
dia of 120 to 140. The x-rays of the abdomen again
showed free air which seemed not to have changed
from previous films. A CT scan of the abdomen re-
ported, "the amount of free air is inordinate for the
surgery done and a perforated hollow viscus is sus-
pected."
The patient was returned to the operating room.
Volume 93, Number 5 - October 1996
235
where a perforation of the cecum was found, along
with massive peritonitis. Cardiac arrest occurred dur-
ing surgery. The patient was temporarily resuscitated,
but arrest occurred again, and ultimately she died
during the operation.
A lawsuit was filed, charging the attending physi-
cian and all his associates with negligence in the delay
in diagnosing and treating the perforation of the co-
lon. A negotiated settlement was the ultimate outcome
of the lawsuit.
Loss Prevention Comments
The evaluation of abdominal distention in the post
cesarean section patient is not an easy problem. Sev-
eral factors could have contributed to the delay in di-
agnosis. The patient seemed to require an unusual
amount of narcotics following her surgery. There was
an apparent lack of continuity of care in that the pa-
tient was operated on by an associate, seen the first
two days after surgery by another associate, and dis-
charged from the hospital by the attending physician
who had not seen her in the hospital.
The readmission was the critical piece in this
puzzle. This patient's distention continued and wors-
ened, as did her pain and tenderness. With different
physicians seeing her almost daily, these very impor-
tant findings were hard to evaluate. It is worth noting
that the attending physician did not come into the
emergency room and examine his patient.
Certainly one would expect free air in the abdo-
men following a cesarean section on the fourth post-
operative day, but "massive" free air? The unusually
high percentage of band forms in the differential could
have been due to intestinal obstruction, persistent aci-
dosis, and dehydration, but it would not be expected
to persist in the absence of infection. The "free air"
did not change significantly in 48 hours as one would
expect, and clinically the patient continued to deteriorate.
Would the results have been any different if the
patient had been reoperated upon as an emergency
on readmission? Or, if the possibility of bowel perfo-
ration had been entertained, would antibiotics have
helped? What was the cause of the perforation in the
first place? Certainly, in the absence of underlying
bowel pathology, the first consideration would have
to be bowel injury at the first operation. Every deci-
sion made in the management of this patient could be
explained and defended. However, the above circum-
stances, taken as a whole, made settlement the best
option.
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236
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Cardiology Commentary and Update
J. David Talley, M.D.*
Ilb/IIIa Platelet Inhibitors in the Management of
Coronary Artery Disease
One of the truly remarkable recent advances in
the management of coronary artery disease is the in-
troduction and use of an antagonist to the Ilb/IIIa plate-
let receptor. One drug with these properties is now
commercially available (ReoPro, Centocor, B.V., Leiden,
the Netherlands) for use in high-risk elective coronary
angioplasty. Other indications are soon to follow. This
issue of ecu will review the use of Ilb/IIIa blocking
agents in the management of coronary syndromes.
The Biology of the Platelet Surface
The platelet surface is composed of many trans-
membrane proteins which promote platelet adhesion
to other platelets and the extracellular matrix. These
proteins are called integrins and are composed of a and
B subunits. The integrin fl|u^63(the glycoprotein Ilb/IIIa
receptor) is responsible for platelet-to-platelet binding
and the integrin (the vitronectin receptor) is es-
sential for cell to extracellular matrix binding, angio-
genesis, cell migration, and proliferation.’ A mono-
clonal antibody (ReoPro) specifically binds the Ilb/IIIa
and vitronectin receptors preventing platelet-to-platelet
binding and neointimal proliferation. ReoPro has im-
proved, substantially, the treatment of thrombosis seen
is acute coronary syndromes, including high and
low-risk coronary angioplasty, acute myocardial inf-
arction, and unstable angina pectoris. The develop-
ment of oral analogues with activity against the
vitronectin receptor offers the promise of halting or
even preventing chronic atherosclerosis.^
‘ J. David Talley, M.D., is Professor of Internal Medicine and
Director of the Division of Cardiology, Department of Internal
Medicine, UAMS Medical Center.
High-Risk Coronary Angioplasty
Coronary angioplasty is plagued by a finite occur-
rence (approximately 5%) of acute closure of the in-
strumented vessel. Fracture of the endothelium, plate-
let activation and aggregation, and vessel thrombosis
are key elements in the pathogenesis of this complica-
tion. ReoPro provides a molecular approach to inter-
rupt this cascade. The landmark EPIC (Evaluation of
c7E3 for the Prevention of Ischemic Complications) trial
confirmed the beneficial effects of ReoPro.^ This study
included 2099 patients who were at high likelihood of
having an adverse outcome after coronary angioplasty.
ReoPro was given as a bolus and followed by a 12
hour infusion. Acute ischemic events were decreased
by 35% primarily due to a reduction of acute myocar-
dial infarction. Patients who received the drug had
more bleeding events, most frequently, at the site of
vascular access. The cause of the bleeding was not
defined; was it the ReoPro, or excessive heparin use?
The findings of the EPIC trial provide the current Food
and Drug Administration approved labeling indica-
tion for the use of ReoPro.
Low-risk Coronary Angioplasty
The beneficial effects of ReoPro include patients
at low to moderate-risk for sustaining an adverse is-
chemic event after coronary angioplasty. The EPILOG
(Evaluation in PTCA to Improve Long-Term Outcome
with ReoPro GP Ilb/IIIa Blockade) trial was prematurely
concluded when the results of the interim analysis of
1500 patients found a three-fold decrease (8.1% to 2.6%,
p = 0.00008) in the occurrence of death and myocardial
infarction. These beneficial effects were so profound
Volume 93, Number 5 - October 1996
237
that the trial was halted by the Data and Safety Moni-
toring Board! The EPILOG trial also found that the
use of lower doses of heparin eliminated the excessive
bleeding rate seen in the EPIC trial. Thus, bleeding is
due to heparin, not ReoPro.
Acute Myocardial Infarction
ReoPro is effective when given as adjunctive treat-
ment with either coronary angioplasty or with a plas-
minogen activator (thrombolytic) to interrupt acute
myocardial infarction. Data from the EPIC trial showed
that ReoPro reduced the likelihood of recurrent vessel
occlusion five-fold compared to standard heparin use.
The combination of another Ilb/IIIa platelet receptor
blocker, integrilin (Cor Therapeutics, South San Fran-
cisco, CA) and t-PA given to patients with acute myo-
cardial infarction, restored normal flow in the infarct
related artery in nearly all patients. ^ The mechanism
of action of ReoPro in this situation is speculative, but
is thought to be related to displacement of fibrinogen
from the Ilb/IIIa receptor. This action prevents fibrino-
gen polymerization and cross-linking and thus the for-
mation of a mature clot.
Unstable Angina Pectoris
Endothelial disruption with sub-
sequent platelet activation and ag-
gregation is the cascade responsible
for the development of unstable an-
gina pectoris. Ilb/IIIa platelet recep-
tor blockers are effective in this clini-
cal syndrome. Several Ilb/IIIa
blockers decrease the number and
duration of ST-segment changes as
documented with ambulatory moni-
toring, and clinical complications in
patients with unstable angina pec-
toris. Definitive benefit awaited
the results of the CAPTURE (Chi-
meric 7E3 Anti-Platelet Therapy in
Unstable Angina Refractory to stan-
dard treatment) trial. This study was
planned to enroll 1,400 patients with
persistent angina pectoris despite the
use of aspirin, heparin, and nitro-
glycerin. The addition of ReoPro to
this medical regiment decreased the
occurrence of death, myocardial in-
farction, and the need for urgent in-
tervention within 30 days to 10.8%
compared to 16.4% with standard
treatment alone, p=0.0064.
Oral Ilb/IIIa Platelet Inhibitors
The competition is rigorous among companies
developing an oral Ilb/IIIa inhibitor (Figure 1). To date,
two main lines of investigation are being pursued, first,
as an adjunct to standard therapy for patients under-
going coronary angioplasty, and secondly, as a substi-
tute to aspirin for chronic administration. In vitro re-
sults of one of these agents used in patients undergo-
ing coronary angioplasty has been reported.®
Xemilofiban (Searle, Skokie, IL, USA) is a prodrug and
is a potent and specific Ilb/IIIa inhibitor that provides
dose dependent platelet inhibition up to 14 days. The
benefits and limitations of the chronic administration
of Xemilofiban are being evaluated in a clinical trial
soon to commence (ORBIT: Oral Glycoprotein Ilb/IIIa
receptor blockade to inhibit thrombosis).
Genentech (South San Francisco, CA) is develop-
ing an oral agent aimed to replace aspirin for chronic
use. This agent (Ro 48-3657) is a double pro-drug which
undergoes intestinal and hepatic conversion and re-
nal excretion. Approximately one-third of the drug is
available as the active agent. This drug has completed
phase I testing (104 patients) where it was shown to
provide more than 75% platelet inhibition. It is now
Research
Preclinical
IND
Phase 1
Phase II
Phase III
Market
Ro 48-3657 (Ge
nentech/Roche)
1
Xemilofiban (Searle/Monsanto)
1
BIBU-104 (Boehringer Ingelheim)
1
(SmithKIine-Beecham)
DUP-728 (Dupo
(Hoechst-Rouss
(Merck)
Glaxo
Lilly/COR ^
Fujisawa ^
RPR ^
Sandoz
>
nt Merck)
el/Cassella) ^
>
Figure 1: There is intense competition among the pharmaceutical companies to be the
first to market an oral llb/IIIa platelet receptor inhibitor. The various stages of develop-
ment are illustrated. Dotted lines indicate assumed stage of drug development. (Infor-
mation used in figure courtesy of M. Okamoto-Kearney .) With permission: Talley JD.
News & views: progress in interventional cardiology (Editorial), f Interven Cardiol
1995;8:206-210.
Abbreviations: COR = Cor Therapeutics, Inc., IND = Investigational New Drug,
RPR = Rhone-Poulenc Rorer Pharmaceuticals, Inc.
238
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Death,
Ml or Revascularization
at 30 Days
Drug
N
Odds Ratio & 95% Ci
Placebo
Ilb/IIIa
EPIC
c7E3
2099
—
12.8%
9.8%
IMPACT-1
Integrelin
4010
- J.
7 9fi
11.6%
9.5%
c7E3
60
23 3%
3 3%
Tcheng
Integrelin
150
-► 6.8
14.3%
7.9%
Theroux
Lamifiban
365
■ —
15.4%
10.3%
Kereiakes
Tirofiban
86 -
-►24.6
5.9%
2.9%
Kleiman
c7E3
70
-► 9.1
20.0%
13.3%
EPILOG
c7E3
1500
-1
-► 4.5
8.1%
3.1%
CAPTURE
c7E3
1050
16.4%
10.8%
TOTAL
9390
1.4B 1./U)
p< 0.0000001
I I I 1 1 1
12.4%
8.5%
0.3 1
3
Figure 2: To date, there have been nine clinical trials using a variety of intravenous lib/
Ilia platelet receptor blockers. All nine studies have shown a decrease in the occurrence of
death, myocardial infarction, or revascularization with the use of the Ilb/IIIa drug. An odds
ratio less than 1 indicates that the use of the drug was detrimental, an odds ratio greater
than 1 indicates a beneficial effect of the medication. (Figure courtesy of EJ Topol and EM Ohman.)
Abbreviations: CAPTURE = Chimeric 7E3 Anti-Platelet Therapy in Unstable Angina
Refractory to standard treatment, EPIC = Evaluation of c7E3 for the Prevention of Is-
chemic Complications, EPILOG = Evaluation in PTCA to Improve Long-Term Outcome
with ReoPro GP Ilb/Illa Blockade, IMPACT = Integrilin to Manage Platelet Aggregation
to Combat Thrombosis.
under evaluation in a phase II trial, TIMI (Thrombin
and Thrombosis Inhibition in Myocardial Infarction and
Ischemia)-12. This trial plans to enroll 260 patients who
have experienced an acute ischemic event. The end-
points are pharmacokinetics, pharmacodynamics, and
safety. A phase III trial is planned to enroll 15,000 pa-
tients with an efficacy endpoint.
Clinical Implications
Ilb/IIIa platelet receptor inhibition represents a sub-
stantial advancement in the treatment of patients with
coronary artery disease. These agents improve the out-
come of patients undergoing high and low-risk coro-
nary angioplasty, acute myocardial infarction, and un-
stable angina pectoris. As seen in Figure 2, Ilb/IIIa plate-
let inhibitors have decreased the occurrence of death,
myocardial infarction, or revascularization from 12.4%
to 8.5%, p<0. 0000001. The risk of bleeding with these
agents is diminished by using lower doses of heparin
and carefully monitoring heparin activity. The intro-
duction of oral agents may relegate aspirin to second
line therapy.
References
1 . Lefkovits J, Plow EF, Topol EJ. Plate-
let glycoprotein Ilb/IIIa receptors in
cardiovascular disease. N Engl J Med
1995;332:1553-1559.
2. Matsuno H, Stassen JM, Vermylen
J, Deckmyn H. Inhibition of integrin
function by a cyclic RGD-containing
peptide prevents neointima forma-
tion. Circulation 1994; 90:2203-2206.
3. The EPIC investigators. Use of a
monoclonal antibody directed against
the platelet glycoprotein Ilb/IIIa recep-
tor in high-risk coronary angioplasty.
N Engl J Med 1994;330:956-961.
4. Ohman EM, Kleiman NS, Talley JD,
Gacioch G, Navetta FI, Carney RJ,
Worley S, Anderson HV, Cohen M,
Kereiakes D, Joseph D, Sigmon KN,
Topol EJ, for the IMPACT-AMI study
group. Simultaneous platelet glyco-
protein Ilb/IIIa integrin blockade with
accelerated tissue plasminogen activa-
tor in acute myocardial infarction (ab-
stract). Circulation 1994;90:1-564.
5. Theroux, P, Kouz S, Knudtson ML,
Kells C, Nasmith J, Roy L, Ave SD,
Steiner B, Ziao Z, Rapold HJ. A ran-
domized double-blind controlled trial
of with the non-peptide platelet GP
Ilb/IIIa antagonist RO-9883 in unstable
angina (abstract). Circulation
1994;90:1-232.
6. Schulman SP, Goldschmidt
-Clermont PJ, Navetta El, Chandra
NC, Guerd AD, Califf RM, Ferguson
JJ, Willerson JT, Wolfe CL, Bahr R, Yakubov SJ, Nygaard
TW, Mason SJ, Brashers L, Charo 1, du Mee, Kitt MM,
Gerstenblith G. Integrelin in unstable angina: A double
Oblind randomized trial (abstract). Circulation 1993;88:1-608.
7. Simoons ML, de Boer MJ, van den Brand MJ, et al. Ran-
domized trial of a GP Ilb/IIIa platelet receptor blocker in re-
fractor unstable angina. Circulation 1994;89:596-603.
8. Nicholson NS, Panzer-Knodle SG, Salyers AK, Taite BB,
Szalony JA, Haas NF, King LW, Zablocki JZ, Keller BT,
Broschat K, Engleman VW, Herin M, Jacqumin P, Feigen
LP. SC-54684A: an orally active inhibitor of platelet aggrega-
tion. Circulation 1995;91 :403-410.
Volume 93, Number 5 - October 1996
239
StMc HesJtli WMcIi
Information provided by the Arkansas Department of Health, Division of Epidemiology
Mercury
During the summer of 1992, several state agencies
discovered that fish in several bodies of water in Ar-
kansas contained methylmercury. From 1992 to 1994,
fish from over 170 lakes and streams were collected
for mercury testing. Twenty-three percent of these
water systems contained fish which exceeded the FDA
action level of 1 ppm in the edible flesh. Refer to the
chart on the following two pages for a list of current
fish consumption notices.
Fish species of greatest concern are largemouth
bass and flathead catfish. The highest levels of mer-
cury have been found in fish from southern Arkansas.
Update
Those considered to be at the highest risk from
methylmercury exposure include developing fetuses
and young children up to seven years of age. Meth-
ylmercury primarily targets the central nervous sys-
tem. In the general population, health effects include
tingling or numbness in the mouth or nerve problems
usually first noticed in the hands and feet. Vision and
hearing could also be affected.
For more information, contact Stan Evans at the
Arkansas Department of Health, Division of Epidemi-
ology at (501)661-2986 during normal business hours.
THE ARMY RESERVE OFFERS UNIQUE AND
REWARDING EXPERIENCES.
As a medical officer in the Army Reserve you will be offered a
variety of challenges and rewards. You will also have a unique
array of advantages that will add a new dimension to your
civilian career, such as:
• special training programs
• advanced casualty care
• advanced trauma life support
• flight medicine
• continuing medical education programs and conferences
• physician networking
• attractive retirement benefits
• change of pace
It could be to your advantage to find out how well the Army
Reserve will treat you for a small amount of your time. An Army
Reserve Medical Counselor can tell you more, call collect :
800-USA-ARMY
ARMY RESERVE MEDICINE. BE ALL YOU CAN BE!
240
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Current Fish Consumption Notices
High Risk Groups*
General Public
Location
Predators**
Non-Predators**
Predators**
Non-Predators**
Lake Columbia
(Columbia County)
Large mouth bass less
than 16 inches in length,
crappie, channel and blue
catfish - no restrictions.
Do not consume all other
predators.
No restrictions
Large mouth bass less than 16
inches in length, crappie,
channel and blue catfish - no
restrictions. No more than 2
meals a month of large mouth
bass 16 inches or longer. Do
not consume all other predators.
No restrictions
Cut-off Creek (from where the creek
crosses Highway 35 in Drew County
to its confluence with Bayou
Bartholomew)
Do not consume
Do not consume
No more than 2 meals
per month
Do not consume
Bayou Bartholomew (from where it
crosses Highway 35 in Drew County to
its confluence with Little Bayou in
Ashlev Countv)
Do not consume
Do not consume
No more than 2 meals
per month
Do not consume
Grays Lake (Cleveland County)
Do not consume
Do not consume
No more than 2 meals
per month
No restrictions
Moro Bay Creek (from Highway 160 to
its confluence with the Ouachita River)
(Bradley County)
Do not consume
Do not consume
Do not consume
No more than 2
meals per month
Champagnolle Creek (to include Little
Champagnolle from Highway 4 to its
confluence with the Ouachita River)
(Calhoun County)
Do not consume
Do not consume
No more than 2 meals
per month
No restrictions
Ouachita River (from Camden to the
north border of the Felsenthal Wildlife
Refuge to include all associated ox-
bow lakes, backwaters, overflow lakes,
and barrow ditches)
(Union, Ouachita, Calhoun Counties)
Blue catfish, channel catfish
and crappie - no restrictions
Do not consume all other
predators.
No restrictions
Blue catfish, channel catfish
and crappie - no restrictions
Do not consume all other
predators.
No restrictions
Felsenthal Wildlife Refuge to the
state line
(Union, Bradley, Ashley Counties)
Large mouth bass less than
13 inches and crappie - no
restrictions Do not
consume all other predators.
No restrictions
Large mouth bass less than 13
inches and crappie - no
restrictions. Do not consume
more than 2 meals per month of
large mouth bass 13-16 inches
in length, blue and channel
catfish. Do not consume all
other predators.
No restrictions
Saline River (from Highway 79 in
Cleveland County to Highway 1 60
bridge
Do not consume
Do not consume
No more than 2 meals
per month
No more than 2
meals per month
Saline River (below Highway 160 to
the Ouachita River)
Do not consume
Do not consume
Do not consume
No restrictions
Chart continued on next page
Volume 93, Number 5 - October 1996
241
Location
High Risk Groups*
General Public
Predators**
Non-Predators**
Predators**
Non-Predators**
Dorcheat Bayou
(Columbia and Nevada Counties)
Do not consume
Do not consume
No consumption of large
mouth bass, 16 inches or
longer. No more than 2
meals per month of all other
predators.
No restrictions
Fouche La Fave River (from Nimrod
Dam to the confluence of the South
Fouche, Perry County)
No consumption of large
mouth bass, 16 inches or
longer. No restrictions for
all other predators.
No restrictions
No more than 2 meals per
month of large mouth bass,
16 inches or longer. No
restictions on all other
predators.
No restrictions
Nimrod Lake
(Yell and Perry Counties)
No consumption of large mouth
bass, 16 inches or longer. No
restrictions for all other
predators.
No restrictions
No more than 2 meals per
month of large mouth bass,
16 inches or longer. No
restrictions on all other
predators.
No restrictions
Cove Creek Lake
(Perry County)
No consumption of large mouth
bass, 12 inches or longer. No
restrictions for all other
predators.
No restrictions
No more than 2 meals per
month of large mouth bass
12-16 inches in length. No
large mouth bass over 16
inches should be eaten. No
restrictions for all other
predators.
No restrictions
Lake Sylvia
(Perry County)
No consumption of large mouth
bass, 16 inches or longer. No
restrictions for all other
predators.
No restrictions
No more than 2 meals per
month of large mouth bass,
16 inches or longer. No
restrictions on all other
predators.
No restrictions
Dry Fork Lake
(Perry County)
No consumption of large
mouth bass, 16 inches or
longer. No restrictions for all
other predators.
No restrictions
No more than 2 meals per
month of large mouth bass,
16 inches or longer. No
restrictions on all other
predators.
No restrictions
Lake Winona
(Saline County)
No consumption of black
bass 16 inches or longer.
No restrictions for all
other predators.
No restrictions
No more than 2 meals per
month of black bass 16
inches or longer. No
restrictions for all other
predators.
No restrictions
Shepherd Springs Lake
(Crawford County)
No consumption of black
bass 16 inches or longer.
No restrictions for all other
predators.
No restrictions
No more than 2 meals per
month of black bass 16-20
inches. No black bass over
20 inches should be eaten.
No restrictions for all other
predators.
No restrictions
Johnson Hole (South Fork of the Little
Red River, Van Buren County)
No consumption of large
mouth bass, 16 inches or
longer. No restrictions for
all other predators.
No restrictions
No consumption of large
mouth bass, 16 inches or
longer. No restrictions for
all other predators.
No restrictions
* Pregnant women, women who plan to get pregnant, women who are breastfeeding, and children under the age of 7 years are considered high risk
groups for health effects due to mercury exposure and as a general rule should not eat fish from the consumption notice areas.
**Predator species include bass, pickerel, catfish, crappie, gar and bowfin. Non-predator species include bream, drum, buffalo, red horse and
suckers.
A meal consists of 8 ounces of fish.
242
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reported Cases of Selected Diseases in Arkansas
Profile for July 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
July 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1994
Campylobacteriosis
38
129
91
153
99
187
Giardiasis
22
78
60
131
51
126
Shigellosis
15
54
75
176
108
193
Salmonellosis
66
217
139
332
165
534
Hepatitis A
39
304
296
663
66
253
Hepatitis B
5
50
38
83
32
60
HIB
0
0
5
6
2
5
Meningococcal Infections
1
27
26
39
36
55
Viral Meningitis
4
15
25
31
48
62
Lyme Disease
1
20
7
11
12
15
Rocky Mountain Spotted Fever
3
9
22
31
8
18
Tularemia
2
13
18
22
19
23
Measles
0
0
2
2
1
5
Mumps
1
1
4
5
5
7
Gonorrhea
irkie
***
5437
***
7078
Syphilis
***
1017
***
1096
Legionellosis
0
1
5
5
10
16
Pertussis
1
4
50
59
24
33
Tuberculosis
20
128
127
271
144
264
*** Unavailable at time of submission.
Volume 93, Number 5 - October 1996
243
The More
You Know
About Us,
The More
You' 11
Prefer U s .
Y
ouTl prefer us, because you are us. Arkansas Managed Care
Organization is the physician sponsored PPO designed to fit the
needs of your local community. More than 1 ,500 physicians state-
wide have found AMCO is the managed care solution that works on
their turf.
To find out more about AMCO, give us a call. You’ll like what you
hear.
Arkansas
Managed Care
Orgariization
#10 Corporate Hill Drive
PO. Box 23803, Little Rock, AR 72221-3803
(501) 225-8470 • Fax (501) 225-7954
HIV/AIDS Surveillance Program
Conducting Follow-up Investigations of
Cases with No Identified Risk
Jan Bunch*
As cases of HIV and AIDS are reported to the
Health Department during routine surveillance, many
cases initially lack risk exposure information. Persons
with HIV or AIDS who are reported without recog-
nized risks for HIV are investigated by surveillance
staff according to standard Centers for Disease Con-
trol and Prevention (CDC) protocols to identify risk
information.
For epidemiologic purposes, HIV/AIDS risk expo-
sures (among persons who have more than one pos-
sible risk for having acquired HIV) have been catego-
rized into hierarchical exposure groups. However, it
is important to collect information on all possible modes
of transmission that are documented in the patient's
medical record.
Collection of behavioral risk data is a crucial part
of monitoring the HIV/AIDS epidemic, since data on
behavioral risks for HIV is necessary for planning and
evaluating prevention activities, following trends,
making projections and identifying unusual transmis-
sion circumstances when they occur.
The HlV/AlDS Surveillance Program works closely
with physicians and health care providers statewide
to promote HIV/AIDS case reporting and in conduct-
ing confidential risk investigations when needed.
Surveillance staff routinely conduct on-site medi-
cal record reviews to assist physicians in meeting case
reporting requirements. However, this service is pro-
vided only with the consent of or at the request of the
physician. In most instances, patient medical records
are reviewed by the physicians or their staff and the
information requested is provided to the HIV/AIDS
Surveillance Program.
In reality, it is not possible to be entirely certain
about the source of HIV infection in all persons; the
classification of AIDS cases according to mode of ex-
posure is based on an assessment of the greatest like-
lihood of transmission in light of knowledge of the
epidemiology of HIV infection.
Jan Bunch is HIV/AIDS Surveillance Administrator at the
Arkansas Department of Health.
Other than this...
<
Q
n
AMBULANCE
ret.......
n
>
r
r
There are only two better vehicles for reaching
Arkansas’ physicians and health care providers.
H
The Journal of the Arkansas Medical Society
and
The Arkansas Medical Society Membership Directory
H
O
O
<
U
Call the Arkansas Medical Society today at
501-224-8967
to inquire about rates and other advertising information.
>
Volume 93, Number 5 - October 1996
245
Arkansas HIV/AIDS Report
1983-1996
HIV In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: County of residence may
change from date of HIV test to date
of AIDS diagnosis.
I County of residence at the time of test for the 3,659 Arkansans reported to be HlV-t- (8/12/96)1
HIV
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
1
Male
100
215
248
413
400
392
352
367
338
195
3,020
83
X
Female
8
26
37
68
85
81
94
90
91
59
639
17
Under 5
1
1
2
8
13
6
3
7
2
1
44
1
5-12
0
1
1
5
1
2
1
0
1
0
12
0
13-19
0
7
8
14
19
25
11
22
12
16
134
4
20-24
12
40
52
71
44
49
64
60
47
24
463
13
25-29
21
70
71
112
105
107
111
85
78
48
808
22
A
30-34
25
50
64
116
120
111
91
102
101
52
832
23
G
35-39
19
36
40
80
88
68
77
69
81
50
608
17
E
40-44
16
17
17
43
50
41
47
50
46
25
352
10
45-49
6
8
18
13
20
26
18
27
24
16
176
5
50-54
2
1
5
8
14
14
10
12
17
11
94
3
55-59
1
3
4
6
3
13
6
7
5
7
55
2
60-64
1
0
1
1
2
6
5
9
8
1
34
1
65 and older
iiiilN
2
1
2
3
5
2
7
7
3
36
1
R
White
87
170
174
328
298
293
278
260
260
131
2,279
62
A
Black
21
69
108
151
184
173
163
184
159
111
1,323
36
C
Hispanic
0
1
3
1
3
4
1
7
3
2
25
1
E
Other/Unknown
0
1
0
1
0
3
4
6
7
10
32
1
Male/Male Sex
65
138
144
245
250
261
242
230
166
79
1,820
50
Injection Drug User (IDU)
13
30
48
74
96
76
65
73
52
15
542
15
R
Male/Male Sex & IDU
19
23
24
32
30
34
26
23
26
12
249
7
wm
Heterosexual (Known Risk)
5
25
26
59
67
68
100
95
66
33
544
15
s
Transfusion
5
5
4
6
8
10
0
2
3
0
43
1
K
Perinatal
1
1
2
8
13
8
4
7
0
0
44
1
Hemophiliac
0
0
6
18
5
6
2
3
5
0
45
1
Undetermined
0
19
31
39
16
10
7
24
111
115
372
10
HIV CASES BY YEAR
341
285
481
485
473
446
457
429
254
3,659
100
Arkansas Department of Health HIV/AIDS Surveillance Program
246
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1996
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501) 661-2387.
NOTE: County of residence may
change from date of HI V test to date
of AIDS diagnosis.
AIDS
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
1
Male
85
77
70
170
176
250
334
253
238
146
1,799
87
X
Female
5
6
10
20
25
35
64
42
36
36
279
13
Under 5
0
1
1
6
6
3
2
1
2
0
22
1
5-12
0
1
0
1
1
0
1
0
2
1
7
0
13-19
0
0
0
4
3
2
4
3
1
2
19
1
20-24
7
5
11
11
14
14
31
22
11
10
136
7
25-29
24
22
13
44
43
67
78
45
47
28
411
20
A
30-34
20
21
21
47
42
73
98
81
75
47
525
25
G
35-39
19
15
20
31
38
55
80
52
49
41
400
19
E
40-44
10
7
4
21
35
28
49
39
35
28
256
12
45-49
5
3
3
14
6
24
28
22
17
13
135
6
50-54
1
1
2
5
6
7
10
12
15
3
62
3
55-59
2
2
4
1
4
8
8
5
6
5
45
2
60-64
1
1
1
1
1
2
6
10
5
1
29
1
65 and older
1
4
0
4
2
2
3
3
9
3
31
1
R
White
74
61
58
141
134
206
273
190
174
96
1,407
68
A
Black
16
20
21
47
66
75
121
102
97
84
649
31
C
Hispanic
0
1
0
0
1
3
3
2
3
2
15
1
E
Other/Unknown
0
1
1
2
0
1
1
1
0
0
7
0
Male/Male Sex
55
59
50
122
120
183
237
166
138
78
1,208
58
Injection Drug User (IDU)
12
4
11
18
29
45
70
46
48
14
297
14
R
Male/Male Sex & IDU
16
6
6
18
17
21
27
23
20
14
168
8
1
Heterosexual (Known Risk)
5
3
7
11
12
24
52
41
35
26
216
10
S
Transfusion
2
7
3
7
11
4
2
4
3
1
44
2
K
Perinatal
0
1
1
6
6
3
3
1
3
0
24
1
Hemophiliac
0
1
1
5
5
4
5
6
7
2
36
2
Undetermined
0
2
1
3
1
1
2
8
20
47
85
4
AIDS CASES BY YEAR
83
80
190
201
285
398
295
274
182
2,078
100
Arkansas Department of Health HIV/AIDS Surveillance Program
[T5] j [H^
I Of the 3,659 Arkansans reported to be HIV+, 2,078 have been diagnosed with AIDS. (8/12/96)1
AIDS In
Arkansas
Volume 93, Number 5 - October 1996
247
Outdoor MD
Information provided by
the Arkansas Game & Fish Commission
Fishing is a key item
on Mike Huckabee's agenda
When that four-pound rice field reservoir bass slammed into the white spinner bait, the biggest thing
hooked was Mike Huckabee.
Arkansas' new governor remembers the occasion well, though it occurred in the early 1980s. He
recalls it to the extent that there's always a white spinner bait in his tackle box. His present plans may not
include a return to the scene of his first catch of a good bass, but fishing will be a personal focal point for
Huckabee - not when he steps down as governor but right now.
He said, "There'll be times when I'll slip away from here (his office) and get out on the river and fish.
It's good for you. It leaves your mind fresher, cleaner, and you're able to work better."
Growing up in Hope, it was natural for Huckabee to do a little cane pole fishing as a child. Then
angling fell by the wayside in his busy teen years, with radio work and beginnings as a preacher weaved
among his other sub-adult activities. A zip through Ouachita Baptist University, marriage and the minis-
try followed, and Huckabee met an angler named Gilbert Hatcher in Pine Bluff in 1981.
"He took me out on the river, and he made me learn the basics. He'd say, 'Here's how you tie on that
lure,' and he'd make me do it. Then I met Herbert Phillips, a great bass fishermen, and he got me to the
rice pond," Huckabee said.
Hooking a sportsman on bass fishing is usually followed by purchase of a bass boat. Huckabee said,
"I got a used bass boat in 1984, a Cajun with a 115-horsepower Mercury motor. Then we moved to
Texarkana, and my church had a building program. I sold the boat - and immediately I missed it."
Again, fishing took a back seat to other activities, including a run at the U.S. Senate that fell short and
a shot at the lieutenant governor's post. He landed that one, but pressures built. A little over a year ago,
Huckabee told his wife, Janet, he needed recreation. Fishing was his choice of a route, adding "I told her
a boat is cheaper than a heart attack."
He said, "My 40th birthday came around last August. Our oldest son was going off to college, and we
took our first vacation in three years. We went to Lake Greeson for my birthday. We were on a deck
overlooking the lake with a bunch of friends, grilling hamburgers, when a boat approached and made a
circle. It was a good-looking bass boat, really good looking. After a while, the boat came back, and a guy
in it held up a sign. I tried to read it, and it got closer. Then I saw the fellow was a friend of mine, and he
held up a sign that said, 'It's yours, Mike.' That was my birthday present, the bass boat. Janet had bought it.
"It was a BassCat Pantera II with a 150-horse Mercury motor, and it was just the right colors. Now
you know why her calls always get through to me here at the governor's office."
Huckabee's fishing is often for largemouth bass but not exclusively. "I may take some live bait along,
and if the bass aren't hitting, then I'll try for some bream or maybe catfish. Back when we lived at
Pine Bluff, I got into some of those really big redear bream down there at
Atkins Lake."
A fishing, and relaxation, delight for Huckabee is the Arkansas River.
He's made friends with it since moving to Little Rock. "The Arkansas River is
never the same," he said. "It's got mystery, it's got intrigue, and it's got that
great fishing. I was at the BASS Masters Classics at Pine Bluff (1984 and 1985
- events that put the Arkansas River on the national bass fishing map). Some-
continued on next page
248
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
times I may not catch anything. I may go up toward Toad Suck, pull up to a sand bar or just lean back in the
boat and watch the sky.
"The river is so interesting right here at Little Rock. Sometimes I'll go (downstream) near the end of the
runway at the airport and just sit in the boat and watch those jets come right overhead. They look like
they're about 20 feet over your head."
Fishing involves the other members of the Huckabee family but to a limited extent, he said. "My wife
likes to fish sometimes but just when she's catching something. My oldest son isn't much on fishing, but
my 16-year-old son fishes and duck hunts. He really likes that duck hunting. My daughter likes getting out
on the boat and the water. With that bass boat, we do some skiing and tubing."
So, do the Huckabee fish wind up on the governor's mansion dinner table? "I've got a propane fish
cooker," he said, "but most of my fishing is catch and release. Crappie is my favorite fish to eat, and Tm
really not a crappie fisherman. Besides, if you figure the cost per pound of fish you catch, you're better
off to go out and buy a fish dinner."
Huckabee's schedule book may become more crowded. There'll be no slacking off on demands
for his time and attention. Budgets, taxes, appointments, political issues all await him daily at the
Capitol - and there's a legislative session coming up in January.
Still, that spiffy Huckabee bass boat will be on the Arkansas River from time to time. "You can
get out of here and be on the river in just a few minutes," he said. "We've got so much potential
here for development on the Arkansas River, and I have something I really want to do. I want to
put that bass boat in the river at Fort Smith and go all the way down to Dumas. Instead of town
meetings, we can have river meetings with people along the way."
Meetings with people are fine, but that Huckabee river trek will surely have a fishing rod or two in the
boat. There'll be a white spinner bait in the tackle box, too.
Welcome P&H Ostomy
Sunbelt Business Brokers is pleased to announce the
sale of Noble Ostomy and Health Services to P&H Os-
tomy and Health Services of Little Rock. Steven Henry
and Raymond Phillips are the principals of P&H and are
planning to expand the current business and further de-
velop the medical supply markets currently served.
L.J. and Maylene Carter started the business 13 years
ago and have established a base in several medical supply
market segments. Henry and Phillips are both experienced
in the sales and management of retail and service companies.
Noble Ostomy is a major supplier of ostomy supplies
in the mid south. P&H will continue to operate from the
current location at 13001 Stacy, Little Rock.
If you are buying or selling a medically related busi-
ness call the best, call 225-6008.
SUNBELT
BUSINESS
brokers ^
®
Sunbelt Business Brokers
11015 C Arcade Drive, Little Rock, AR 72212
Opportunity for practitioner to earn low stress extra
income practicing preventative medicine with flex-
ible hours and flexible schedule in Arkansas. Ten
minutes from downtown Memphis, predominately
healthy patient population. Nutrition/weight, loss/
weight training background helpful. Part-time/full-
time, day/evening/Sat. office hours available. Send
CV to:
Preventative Medicine Clinic
P.O. Box 3096
Memphis, Tennessee 38173
or call: (501)732-3988
Volume 93, Number 5 - October 1996
249
Western W'lldlife
As Kascrnien movni MVs(. pioneers
foiind.animuls as eiotir as ihe
buffalo, prairie Jogs, bears, beaver//tiglmnr
sbrep, rougars. wolves and raidesrf^s.
The eagle became a national s«7nbol. <i : j ' ‘
jk I he eagle becany a national s«7nbol. <i : j ■ ‘ ^ •'/
£yyuJ^^jZa^ h 2^
oaJ Ima.
/ould like to
all. your pei
^siblcfor’"
ammogro”'
,„ereelse‘o
...me there
ror more
information
on how
you can help,
call AHCAF at
(501)221-3033
or (800) 950-8233
Arkansas Health Care
Access Foundation, Inc.
P those physicians who volunteer ^
through the Arkansas Health j
/ Care Access Foundation, J
Thank You!
As you can see from a sampling of
i letters we have received, your
IL involvement in our program is i
H|L appreciated and in many ijn
cases life-saving.. ,
Pn/hof
LlM&L/ZarJk. /3./C
New Members
BULL SHOALS
Crow, Ronald Melton, Internal Medicine. Medi-
cal Education, University Health Sciences College of
Osteopathic Medicine, Kansas City, MO, 1974. Intern-
ship, Wright-Patterson AFB, Dayton, Ohio, 1975. Resi-
dency, Keesler AFB, Biloxi, MS, 1978. Board certified.
CONWAY
Gray, George T., Ill, Family Practice. Medicine
Education, Oklahoma State University College of Os-
teopathic Medicine, Tulsa, 1985. Internship Harborside
Hospital, St. Petersburg, FL, 1986. Board certified.
FAYETTEVILLE
Fink, Roger Lee, II, Pathology. Medical Educa-
tion, University of Missouri School of Medicine, Co-
lumbia, MO, 1991. Residency, UAMS, 1996. Board
pending.
Harris, David Jay, Radiology. Medical Education,
University of Oklahoma, Oklahoma City, 1992. Resi-
dency, University of Oklahoma, 1996. Board pending.
Saitta, Michael R., Rheumatology. Medical Edu-
cation, Johns Hopkins, Baltimore, MD, 1984. Intern-
ship/Residency, Johns Hopkins Hospital, 1985, 1987.
Board certified.
Travis, Patrick M., Hematology/Oncology. Medi-
cal Education, UAMS, 1990. Internship/Residency,
UAMS, 1991/1993.
HOT SPRINGS
Agee, Kimberly R., Pulmonary & Critical Care
Medicine. Medical Education, UAMS, 1985. Internship/
Residency, Kansas University Medical Center, 1986/
1988. Board certified.
JONESBORO
Patel, Dharmendra V., Cardiology. Medical Edu-
cation, MS Ramaiah Medical College, Banglore Uni-
versity, India, 1989. Internship/Residency, ETSU Af-
filiated Hospitals, 1993/1996. Board certified.
LEWISVILLE
Nix, John Edward, Family Practice. Medical Edu-
cation, UAMS, 1993. Intemship/Residency, AHEC-SW,
1994/1996.
LITTLE ROCK
Forte, Judith Ljmn, Transplant Nephrology. Medical
Education, UAMS, 1989. Internship, UAMS, 1992. Fel-
lowships, UAMS, 1994 and North Carolina Baptist
Hospital, Bowman Gray School of Medicine, 1996.
Board certified.
Greenwood, Denise Rochelle, General Surgery &
Diseases of the Breast. Medical Education, University
of Texas at Galveston, 1987. Residencies, State Uni-
versity, Kings County Hospital Center, Brooklyn, NY,
1988; New Hanover Memorial, Wilmington, NC, 1990;
and Marshall University School of Medicine, Hunting-
ton, WV, 1992.
Jaffar, Muhammad, Anesthesiology/Critical Care.
Medical Education, UTESA University School of Medi-
cine, Santo Domingo, Dominican Republic, 1986. In-
ternship/Residency, Maimonides Medical Center,
Brooklyn, NY, 1992/1995. Board pending.
Reid, Graham M., Psychiatry. Medical Education,
UAMS, 1978. Internship, Fort Smith, AR, 1979. Resi-
dency, University of Texas, Galveston, 1982. Board cer-
tified.
Ruddell, Deanna N., Allergy-Immunology. Medi-
cal Education, UAMS, 1991. Internship/Residency,
Arkansas Children's Hospital, 1992/1994. Board certified.
MOUNT IDA
Bearden, Jeffrey Charles, Family Practice. Medi-
cal Education, UAMS, 1993. Internship/Residency,
AHEC-NE, 1994/1996. Board pending.
PINE BLUFF
Stark, James Edgar, Diagnostic Radiology. Medi-
cal Education, Univ. of South Alabama, Mobile, 1988.
Internship/Residency, UAMS, 1989/1992. Board certified.
RUSSELLVILLE
Coombe Moore, Jackie M., Psychiatry. Medical
Education, UAMS, 1992. Internship, Pine Bluff AHEC,
1993. Residency, UAMS, 1996.
SHERWOOD
Sanders, Kelli Keene, Family Practice. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
1994/1996.
SPRINGDALE
Cunningham, Darrin D,, Obstetrics/Gynecology.
Medical Education, Oklahoma State University, Tulsa,
1991. Internship/Residency, Hillcreast Health Center,
Oklahoma City, OK, 1992/1996. Board eligible.
Volume 93, Number 5 - October 1996
251
OUT OF STATE
Bailey, Christopher Arnold, Pulmonary & Criti-
cal Care, Internal Medicine, Pediatrics. Medical Edu-
cation, University of Oklahoma College of Medicine,
Oklahoma City, 1989. Internship/Residency, Univer-
sity of Oklahoma Health Sciences Center, 1990/1993.
Board certified.
Itzig, Charles Blum, Jr., General Surgery. Medi-
cal Education, University of Mississippi School of
Medicine, Jackson, 1965. Internship, Baptist Memo-
rial Hospital, Memphis, TN, 1966. Residency, VA Hos-
pital, Memphis, TN, 1970. Board certified.
RESIDENTS
Guerrero, David Andrew, Family Practice. Medi-
cal Education, Stanford School of Medicine, Stanford,
CA, 1995.
Hill, Chad, Obstetrics/Gynecology. Medical Edu-
cation, UAMS, 1994.
STUDENTS
Christopher Scott Bryant
Brian McDonald Cate
Brent Daniel Chavis
David Wayne Crownover
Brian E. Deuter
Andrew Alex Finkbeiner
Martha Gene Garrett-Shaver
Charles Kristian Hanby
Katherine Anne Haynes
Brent Edward Holt
David Edward Keller
James Stacey Klutts
Khim Kirsten Lam
Russell Allen Linsky
Ellen Lu
Andrew Ryan Martine
Bill R. McCourtney, II
Brian Blake Norris
Rebecca Lynn Osborne
Gill Gibson Pillow
James Hargraves Pillow
Angela Michelle Price
Tara Patrice Reynolds
Rusty Lynn Roberts, Jr.
Philip K. Sadler
Kai Sheng
Susanna E. Shermer
Chad Leon Sherwood
Brian Rush Simpson
Christopher William Sorrels
Aaron Michael Spann
Justin Don Warner
Aaron Eugene White
Mark Courtney Williams
W. Frank Williams
Lonnie Benton Wright
252
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
rxifessionel S^oiectxon Exclusively since 1899
To reach your local office, call 800-344-1899.
A
Your Spouse is the
of Our Organization
Membership in the Medical Society Alliance will provide your spouse with the following tools:
• Education and opportunities to impact legislative issues that affect your profession
• Participation in community health education and action projects that enhance the image of the medical
community
• Support for the future of medicine through assistance to doctors in training (AMA- ERE)
• A peer group that understands the challenges unique to physicians and their families
• A stronger, unified voice for the family of medicine
Call the AMSA at 501-224-8967 to ask whether your county has an organized alliance. If it doesn’t, your
spouse can become a Member-at large and will receive all the publications and information from state and
national, as well having an opportunity to participate in state- wide projects.
Show your support for your spouse by giving the gift of membership;
SEND DUES ($40 plus ) * TO:
AMS Alliance
P.O. Box 55088
Little Rock, AR 72215-5088
* County Dues Vary
Name :
Address: County:
City: ^State: Zip:
Phone: Legislative District:
Would you be willing to contact your Senator or Representative regarding health care issues? Yes No
Physician’s Name: DOB: Specialty:
Make checks payable to:
ARKANSAS MEDICAL
SOCIETY ALLIANCE
Arkansas Medical Society Alliance News
OFFICERS ATTEND NATIONAL
CONVENTION
Ruth Mabry, president; Evelyn Thomas, immediate
past president; and Barbara Moody, president elect;
attended the American Medical Association Alliance
convention in Chicago June 22-25.
WILLIE OATES BEARS OLYMPIC
TORCH
Willie Oates, who has been a state and county
president, was among those chosen to help carry the
Olympic Torch through Arkansas. Torch bearers were
chosen on the basis of their leadership and service to
community organizations.
Willie says, “Being a torch bearer was the most
exciting thing I have ever done; and I have done a lot of
exciting things — but it made goose bumps on my arms to
see the crowd laughing and crying at the same time — made
me proud to be an American.”
She said the young man with her was from the School
for the Deaf and served as her escort — all torchbearers had
escorts.
FIFTY-YEAR CLUB FOUNDED
Twenty-five persons who have been members of the
AMSA for 50 years or longer were honored at the Annual
Session. During the Installation Luncheon at Cafe St.
Moritz, the four 50-year members present were presented
with certificates of recognition and paperweights featuring
the Alliance logo. The mementos were mailed to those
who could not attend. Every member attending
convention also received “Memories,” papers written by
AMSA Historian Rita Rodgers, highlighting the
accomplishments and recollections of some of the 50-year
members. President Evelyn Thomas stressed the important
role these members continue to play as part of the
organization’s “heritage.”
Left: Mrs. Jeanne Hundley,
formerly of Pine Bluff, now
of Little Rock, is a 50-year
member who has been state
president and president of
two county alliances.
Mrs. Corrine Price,
member-at-large for
58 years, is presented
her certificate and
mementos by Rita
Rodgers, (left)
AMSA historian
Mrs. Marguerite
Henry and Mrs.
Marie Smith
display their 50-
year honors
Volume 93, Number 5 - October 1996
255
ARKANSAS MEDICAL SOCIETY
FALL MEETING
NOVEMBER 16-17, 1996
LAKE HAMILTON RESORT
HOT SPRINGS, ARKANSAS
The Arkansas Medical Society conducts a Fall Meeting every two years for the general membership and the
House of Delegates to discuss issues to be addressed in the upcoming session of the Arkansas General
Assembly. The intrusion of government into the practice of medicine grows stronger every year and 1997
will be no exception!
Among the topics to be discussed are:
*Disclosure by third-party payors of policies affecting patient care and choice...
*The scope of practice expansion of allied health providers including nurses, acupuncturists, podiatrists,
CRNA's, optometrists and others (this includes limitations on medical assistants, surgical techs and other
physician trained personnel)...
*Efforts by trial lawyers to increase your exposure thereby increasing your insurance premiums...
*Public health issues from AIDS, smoking and guns to motorcycle helmets and the testing of doctors for
infectious diseases...
*Plus much more...
The proposed bills for the 1997 Legislative Session may change the way you practice medicine, and your
presence at the Arkansas Medical Society Fall Meeting is very important.
SATURDAY. NOVEMBER 16. 1996
9:00 a.m. Leadership Workshop for Officers & Councilors
1 1 :00 a.m. Council Meeting
12:30 p.m. Afternoon free for golfing, shopping or watching the Hogs on TV
6:30 p.m. Happy Hour - Spouses invited
7:00 p.m. Y)mx\ex - Spouses invited
SUNDAY. NOVEMBER 17. 1996
9:30 a.m.
10:30 a.m.
Noon
Committee Meetings (TBA)
Brunch - Spouses invited
House of Delegates
Discussion of Probable 1997 Legislative Issues
2:30 p.m.
or
Council Meeting (Wrap-up and Budget)
3:00 p.m.
Casual attire appropriate for all events
For More Information, Contact the Society office at
501-224-8967 or 1-800-542-1058
256
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
Steven R. Nokes, M.D., Editor
Authors
Steven R. Nokes, M.D.
W. Bradley Pierce, M.D.
Jeffrey J. Carfagno, M.D.
Beverly A. Beadle, M.D.
John H. Yocum, M.D.
History:
A 42-year-old woman presented with right knee and leg pain. An EMG revealed an isolated peroneal nerve
abnormality. An MR scan of the right knee and calf were performed.
Figure 1B
Figure 1A
Figure 2A
Figure 2B
Figures:
Figures 1 A and B. Axial T 1 and fast spin echo T2 weighted images at the level of the fibular head.
Figures 2A and B. Axial fast spin echo T2 weighted images with and without fat saturation through the upper calf.
Volume 93, Number 5 - October 1996
257
Peroneal Nerve Ganglion Cyst
Diagnosis:
Peroneal nerve ganglion cyst.
Findings:
A small (7mm) round mass is seen in the common peroneal nerve posterior to the fibular head. It is low signal on
T1 weighting and very high signal on T2 weighting. The mass did not enhance. The findings are characteristic of a
ganglion cyst. High signal is seen in the tibialis anterior and extensor digitorum longus muscle on T1 and T2 weighted
images characteristic of both fatty replacement (T 1 high signal) and denervation edema (T2 high signal) secondary to
the cyst.
Discussion:
The pathogenesis of peroneal nerve ganglion cysts is debated. One school holds that these represent cystic
degeneration of the nerve sheath, but most believe the origin is from the synovial capsule of the proximal tibiofibular
joint with extension along the recurrent superior tibiofibular articular branch of the common peroneal nerve. Once the
cyst reaches the common peroneal nerve it loses its communication with the joint. The ganglion may enlarge at this
point and present as a palpable mass. Signs and symptoms include pain and paresis of the foot extensors.
MR imaging is the technique of choice in evaluation an isolated peroneal nerve palsy. The exam requires high
resolution imaging with gadolinium to exclude a neuroma. Muscular denervation and atrophy are important secondary
signs of a lesion that are difficult to appreciate without STIR or fat-saturation techniques.
Surgical resection is the treatment of choice. Excision without neurologic loss is possible as the nerve fibers are
not primarily involved by the pathophysiologic process.
References:
1. Stack RE, Bianco AJ, MacCarty CS. Compression of the common peroneal nerve by ganglion cysts. J Bone Joint Surg 1965;
47-A: 773-778.
2. Coakley FV, Finlay DB, Harperum, Allen MJ. Direct and indirect MRI findings in ganglion cysts of the common peroneal nerve.
Clin Radiol 1995; 50:158-159.
3. Spillane RM, Whitman CJ, Cheu FS. Peroneal nerve ganglion cyst. AJR 1996; 166:682
Authors:
Editor: Steven R. Nokes, M.D. is associated with Radiology Consultants in Little Rock.
Contributor: W. Bradley Pierce, M.D. is associated with Radiology Consultants in Little Rock.
Contributor: Jeffrey J. Carfagno, M.D. is with Maumelle Family Practice.
Contributor: Bevedy A. Beadle, M.D. is with Neurology Associates of Little Rock.
Contributor: John H. Yocum, M.D. is with Little Rock Orthopedic Clinic.
258
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
In Memoriam
Maurice J. Elovitz, M.D.
Dr. Maurice J. Elovitz, of Austin, TX, and formerly of Helena,
AR, and Boston, Mass., died Thursday, September 5, 1996. He
was 64. He is survived by two daughters, Charlene Elovitz, and
Audrey Glaser and her husband, Bart, all of Austin, TX; sons Rob-
ert Elovitz, Jonesboro, AR, and Russell Elovitz and his wife, Ellen,
Olney, Maryland; sister, Betty Adelman, Delmar, NY; his former
wife, Rhoda Elovitz, Austin, TX, and three grandchildren.
Resolutions
William Wood Abbott, M.D.
WHEREAS, the members of the Pulaski County Medical Society note with heart-felt sorrow the recent death of
an esteemed member, William Wood Abbott, M.D.; and
WHEREAS, Dr. Abbott served this organization as an active and faithful member for over thirty-eight years; and
WHEREAS, his devotion to his country was evidenced by his distinguished service as a pilot in the United States
Air Force during World War II; and
WHEREAS, Dr. Abbott's caring and capable practice of Anesthesiology earned him the respect and devotion of
his patients and colleagues alike;
BE IT THEREFORE RESOLVED:
THAT, this resolution be adopted and placed in the archives of this Society; and
THAT, a copy of this resolution be sent to Dr. Abbott's family as an expression of our genuine sympathy; and
THAT, a copy be made available to The Journal of the Arkansas Medical Society for publication.
Walton R. Warford, M.D.
WHEREAS, the membership of the Pulaski County Medical Society is saddened to learn of the recent death of a
respected member, Walton R. Warford, M.D.; and
WHEREAS, Dr. Warford was a loyal member of this Society for over half a century; and
WHEREAS, Dr. Warford's memory will live on as a testament to the highest ideals of medicine;
BE IT THEREFORE RESOLVED:
THAT, this resolution be adopted and placed in the permanent files of this Society; and
THAT, a copy be forwarded to Dr. Warford's family as a token of our sincere sympathy; and
THAT, a copy be forwarded to The Journal of the Arkansas Medical Society for publication.
All Resolutions Adopted By Order of the Memorials Committee
Board of Directors Fred O. Henker, III, M.D., Chairman
August 21, 1996 James W. Headstream, M.D.
Bruce E. Schratz, M.D.
Volume 93, Number 5 - October 1996
259
Things To Come
ARKANSAS LOCATION
October 25 and 26
Breast and Cervical Cancer Screening and Diag-
nosis. UAMS Campus, Little Rock. Interactive video
site available statewide. CME hours available. For more
information, call Dianne Crippen, R.N., Arkansas De-
partment of Health, at (501) 661-2636.
ARKANSAS LOCATION
November 16 and 17
Arkansas Medical Society Fall Meeting. Lake
Hamilton Resort, Hot Springs. For more information,
call (501) 224-8967 or 1-800-542-1058.
November 1-3
New Developments in the Pathogenesis & Treat-
ment of NIDDM (non-insulin dependent diabetes
mellitus). Radisson Resort, Scottsdale, Arizona. Spon-
sored by the American Diabetes Association of Ari-
zona and the National Institute of Diabetes and Diges-
tive and Kidney Diseases. For more information, call
(602) 995-1515.
November 14 - 17
15th Annual Scientific Meeting - Pain and Dis-
ease; Causes, Consequences, and Solutions. Sheraton
Washington Hotel, Washington, DC. Sponsored by the
the American Pain Society. For more information, call
(847) 375-4715.
November 20 - 24
90th Annual Scientific Assembly - Yesterday's
Caring with Today's Technology. Baltimore Conven-
tion Center, Baltimore, Maryland. Sponsored by the
Southern Medical Association. For more information,
call (800) 423-4992 or (205) 945-1840.
December 7
Cardiology Seminar. Washington University Medi-
cal Center, St. Louis, Missouri. Sponsored by the Of-
fice of Continuing Medical Education, Washington Uni-
versity School of Medicine. For more information, call
1-800-325-9862.
February 8-10, 1997
12th Annual Mardi Gras Anesthesia Update in
New Orleans. Westin Canal Place Hotel, New Orleans,
Louisiana. Sponsored by the Department of Anesthe-
siology & Center for Continuing Medical Education,
Tulane University Medical Center. For more informa-
tion, call (504) 588-5466 or 1-800-588-5300.
February 9-14, 1997
Advances in Imaging; 1997. Manor Vail Lodge,
Vail, Colorado. Sponsored by the Departments of Ra-
diology at Tulane University Medical Center and Loui-
siana State University School of Medicine. For more
information, call (504) 588-5466 or 1-800-588-5300.
Keeping Up
November 2
Third Regional Holt-Krock Pediatric Conference.
Time: 8;15 a.m. to 2;30 p.m. Location: Sparks Regional
Medical Center Education Center. Program presenters:
Holt-Krock Clinic, Sparks Regional Medical Center and
AHEC. Accrediting organization sponsoring program:
AHEC-Fort Smith.
November 2-3
American College of Physicians - Fall Chapter
Meeting. Time: Registration and continental Breakfast,
8:30 a.m. Location: Holiday Inn West, Little Rock. Pro-
gram presenters: UAMS Department of Internal Medi-
cine. Accrediting organization sponsoring program: UAMS
College of Medicine.
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category I of the Physiciarr's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/ General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
260
JOURNAL OE THE ARKANSAS MEDICAL SOCIETY
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon, Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society/ Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Spine Center Conference, 1st Wednesday, 7:00 a.m.. Southwestern Bell/Arkla Room. Light Breakfast provided.
Urology Grand Rounds, September 17th and November 5th, 5:30 p.m.. Southwestern Bell/Arkla Room, Refreshments provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
As an organization accredited for continuing medical education by the Accreditation Council for Continuing Medical Education, the
University of Arkansas for Medical Sciences certifies the following continuing medical education activities meet the criteria for Category I
of the Physician's Recognition Award of the American Medical Association.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTl/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS Hospital
Volume 93, Number 5 - October 1996
261
OB/GYN Fetal Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Eriday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology/Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Eciward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
262
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/ Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital CME Conference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Gynecologic Malignancies, 3rd Thursday every other month, 7:00 a.m., various area hospitals
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month at
Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 5
October 1996
263
Advertisers Index
Advertising Agencies in italics
AMS Benefits inside back
Affordable Life Insurance insert
Arkansas Children's Hospital back cover
Autoflex Leasing inside front
Consumer Quote USA 234
Freemyer Collection System 226
The Medical Protective Company 253
Williams Marketing Services
Riverside Motors, Inc 225
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory 223
Strategic Marketing
State Volunteer Mutual Insurance Company 218
The Maryland Group
Southwest Capital Management 221
Marion Kahn Communications, Inc.
U.S. Air Force 226
BJK&E Specialized Advertising
U.S. Air Force Reserve 217
HMS Partners, Inc.
U.S. Army Active 236
Young & Rubicam, Inc.
U.S. Army Reserve 240
Young & Rubicam, Inc.
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
journal. Material appearing in The Journal of the Arkansas
Medical Society is protected by copyright. Manuscripts
may not be reproduced without the written permission of
both author and The Journal of the Arkansas Medical Society.
The Journal of the Arkansas Medical Society reserves the
right to edit any material submitted. The publishers accept
no responsibility for opinions expressed by the contributors.
All manuscripts should be submitted to Tina G. Wade,
Managing Editor, Arkansas Medical Society, P.O. Box
55088, Little Rock, Arkansas 72215-5088. A transmittal
letter should accompany the article and should identify
one author as the correspondent and include his/her
address and telephone number.
MANUSCRIPT STYLE
Author information should include titles, degrees,
and any hospital or university appointments of the
author(s). All scientific manuscripts must include an
abstract of not more than 100 words. The abstract is a
factual summary of the work and precedes the article.
Manuscripts should be typewritten, double-spaced, and
have generous margins. Subheads are strongly encour-
aged. The original and one copy should be submitted.
Pages should be numbered. Manuscripts are not re-
turned; however, original photographs or drawings will
be returned upon request after publication. Manuscripts
should be no longer than ten typewritten pages. Excep-
tions will be made only under most unusual circum-
stances.
Along with the typed manuscript, we encourage you
to submit an IBM-compatible 5 1/4" or 3 1/2" diskette
containing the manuscript in ASCII format. The manu-
script on diskette must be in the same format as stated
above. We will return the diskette upon request.
REFERENCES
References should be limited to ten; if more than ten
are listed, the author(s) may designate the ten most
significant to be printed and readers will be referred to the
authors(s) for the complete list. References must contain,
in the order given: name of author(s), title of article, name
of periodicals with volume, page, month and year. Refer-
ences should be numbered consecutively in the order in
which they appear in the text. Authors are responsible for
reference accuracy.
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Illustrations should be professionally drawn and/or
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ferred. They should not be mounted and should have the
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are necessary, it is understood that the author(s) will be
responsible for the reproduction costs.
REPRINTS
Reprints may be obtained from The Journal office and
should be ordered prior to publication. Reprints will be
mailed approximately three weeks from publication date.
For a reprint price list, contact Tina G. Wade, Managing
Editor, at The Journal office. Orders cannot be accepted for
less than 100 copies.
HEALTH SCIENCES UBRARY^^
UNIVERSITY OF MARYLAND AT
BALTIMORE
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
THE JOURNAL
OF THE ARKANSAS
ASSISTANT EXECUTIVE VICE PRESIDENT
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
ObstetricsIGynecology
hiterval Medicine
Surgery
Family Practice
UAMS
MEDICAL SOCIETY
Volume 93 Number 6 November 1996
CONTENTS
FEATURES
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
269 Long Term Complication of Button Gastrostomy Tube
Scientific Article
Paul A. Hellstern, M.D.
C.V. Netchvolodoff, M.D.
]N.A. Qureshi, M.D.
T71 Medicine in the News
Health Care Access Foundation Update
AMS Adopts Policy Prohibiting Society Funds to be Invested in
Tobacco Related Stocks, Bonds or Mutual Funds
Important Changes in Antitrust Enforcement Policy for Physician
Networks
Physician Biographical Information Now on AMA Web Site
279 New Member Profile
Mark Michael Allard, M.D.
281 Anaphylaxis: Multiple Etiologies - Focused Therapy
Scientific Article
fohn M. James, M.D.
289 There Ain't No Justice
Loss Prevention
J. Kelley Avery, M.D.
297 Getting Acquainted with Gerald A. Stolz, Jr., M.D., Newly
Elected Chairman of the AMS Council
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
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Copyright 1996 by the Arkansas Medical Society.
DEPARTMENTS
277 AMS Newsmakers
291 Cardiology Commentary & Update
295 State Health Watch
298 Outdoor MD
299 New Members
303 Radiological Case of the Month
307 In Memoriam
308 Things to Come
309 Keeping Up
Cover artwork, titled "Reveille," is by Russellville artist Bill Garrison. Artwork made available
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Ken LaMastus, Executive Vice President
Scientific Article
Long Term Complication of Button
Gastrostomy Tube
Paul A. Hellsterri; M.DA
C.V. Netchvolodoff,
W.A. Qureshi,
Introduction
The early eighties has seen the introduction of
percutaneous endoscopic gastrostomy (PEG) tubes,
with widespread benefits for patients who would oth-
erwise require surgical placement of feeding tubes.’
As more patients who are not nursing home depen-
dent, require gastrostomy tubes, less conspicuous and
cumbersome feeding tubes to prevent interference with
their lifestyles have been developed. With the intro-
duction of the button in 1984, these objectives have
been achieved with relatively few complications, most
occurring during placement.^ We believe this case re-
port is the first reported major long term complication
of a button gastrostomy.
Case Report
A 73-year-old white male with a long history of
tobacco abuse was diagnosed in August 1991 with a
T^NoMo squamous cell carcinoma of the buccal mu-
cosa and right mandible. He underwent resection and
reconstructive surgery. Post-opera tively, he developed
Methacillin Resistant Staphylococcus Aureus (MRSA)
infection at the surgery site which was treated suc-
cessfully. In December 1991, he underwent Ponsky PEG
placement because of dysphagia and poor nutritional
status. Ten days after placement, erythema was noted
around the site. Gulture grew out MRSA. It was felt
that the patient was colonized since the erythema im-
proved spontaneously over several days.
* Paul A. Hellstern, M.D., is a Gastroenterology Fellow at
UAMS and is affiliated with John L. McClellan Memorial
VAMC.
** C.V. Netchvolodoff, M.D., is Associate Professor of Medi-
cine, Division of Gastroenterology, at UAMS and is affili-
ated with John L. McClellan Memorial VAMC.
*** W.A. Qureshi, M.D., is Assistant Professor of Medicine, Di-
vision of Gastroenterology, at UAMS and is afiliated with
John L. McClellan Memorial VAMC.
In August 1992, he returned for a PEG-tube check
and possible replacement with a button. It was de-
cided to replace the PEG with a button because the
patient was active and wished a less conspicuous tube.
The PEG was removed without incident, endo-
scopically. After measuring the tract length, a 24 French
2.4 cm. button was placed.
He did well until almost one year later, when he
returned before his scheduled appointment complain-
ing of drainage and mild redness around the button
site. On physical exam, he had no abdominal pain or
fever. The button was flush with the abdominal wall
and freely moveable along its longitudinal axis. The
exudate was cultured and subsequently grew MRSA.
He was placed on oral as well as topical antibiotics
and instructed to return in one week.
When he returned, the button was protruding as-
sociated with raised surrounding tissue. The peristomal
site was tender with drainage and exudate on pres-
sure (see photographs). Fluid would not flow through
the button. It was not freely movable and could not be
removed with the obturator. We felt the button had
migrated into the abdominal wall. At endoscopy only
a dimpled area marked the previous button site on the
inside wall of the stomach. When the button was ma-
nipulated, a small amount of exudate was noted en-
tering the stomach. A Dobhoff tube (DHT) was placed
and appropriate antibiotics started. Surgical consult
was requested for button removal. At surgery the but-
ton was located in the subcutaneous tissue was re-
moved and a 30cc abscess pocket was drained. Cul-
tures grew out Klebsiella Pneumoniae and Enterococ-
cus. After drainage and antibiotic treatment the in-
fected tract closed gradually over the next month.
One month later, a new Ponsky PEG was placed
without problems. It was rechecked a week later and
the patient had not experienced any difficulties.
Volume 93, Number 6 - November 1996
269
Discussion
Since the introduction of the button’ in 1984, there
have been few reported complications. Most of the
major complications occurred during placement.^ There
are two reports of migration with subsequent obstruc-
tion, both relieved endoscopically.’'' There have been
other minor complications described by Gauderea^ and
Foutch.’’ To our knowledge this is the first reported
major complication from a long-term button.
There are several issues in this case which need to
be mentioned. The patient had been colonized by
MRSA for two years without problems. This and the
Klebsiella and Enterococcal organisms previously found
in the patient’s urine probably infected the closing PEG
track. Continued attempts at feeding through the PEG
site allowed collection of Ensure within the abdominal
wall potentiating abscess formation. Secondly, al-
though the patient had documented recurrent cancer,
his overall condition remained stable and he had re-
ceived no recent chemotherapy or radiation treatment
to alter his immune defenses markedly.
This case report stresses several key points for con-
tinuing PEG/Button follow-up, as well as instruction
for signs of infection and other PEG complications.
Despite early antibiotics, infections may develop and
close supervision in all patients with early signs of
possible infection is necessary. Another important point
may be the interruption of tube feeds until the infec-
tion is controlled. This may mean admitting the pa-
tient into the hospital for total parental nutrition. Cer-
tainly appropriate antibiotics as well as cultures should
be obtained. As in this patient, a knowledge of previ-
ous infections may affect one choice of initial antibi-
otic. In conclusion, this case illustrates a late term com-
plication of a button. Aggressive therapy and close
follow-up is necessary to prevent major late infectious
complications.
References
1. Gauderer MWL, Picha GJ, Izant RJ, JR. The Gas-
trostomy button, a simple skin level, non-refluxing
devise for long-term enteral feedings, J Pediatric Surg
1984; 19:803-805.
2. McQuaid KR, Little TE. Two fatal complications re-
lated to Gastrostomy "button" Placement, Gastrointes-
tinal Endoscopy 1992;38(5): 601-3.
3. Berman JH, Radhakrishman J, Kraut JR. Button
Gastrostomy Obstructing the ileocecal valve removed
by colonoscopic retrieval. Journal of Pediatric Gastro-
enterology and Nutrition 1991;13(4):426-8.
4. Brown BJ, Kaufman B, Brown C. Internal displace-
ment of a gastrostomy button: An unusual cause of
gastric outlet obstruction. Journal of Pediatric Surg
1993;28(12): 1575-6.
5. Gauderer MWL Olsen MM, Stellato TA, Dolcler ML.
Feeding gastrostomy button: experience and recom-
mendations 1988, Journal of Pediatric Surg 1988;
23(l):24-8.
6. Foutch PG, Talbert GA, Gaines JA, Sanowski RA.
The Gastrostomy Button. A prospective assessment
of safety, success, and spectrum of use, Gastro intes-
tinal Endoscopy 1989;35(l):41-4.
270
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Medicine in the News
Health Care Access Foundation
As of October 1, 1996, the Arkansas Health Care
Access Foundation has provided free medical service
to 11,669 medically indigent persons, received 21,982
applications and enrolled 42,877 persons. This program
has 1,739 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
AMS Adopts Policy Prohibiting Society
Funds to be Invested in Tobacco Related
Stocks, Bonds or Mutual Funds
Following the lead of the AMA, the Council of the
AMS has adopted a policy prohibiting the investment
of any Society funds in stocks, bonds or mutual funds
which have any connection to the tobacco industry.
This would include any funds of the AMS or any of its
subsidiaries and foundations. The AMA has compiled
a list of 13 stocks and 1,474 mutual funds that include
companies that manufacture or invest in tobacco com-
panies. The AMS Council strongly encourages all AMS
members to consider similar action with their personal
and business investment portfolios.
All of this came from the August 25, 1996, AMS
Council Meeting, where after Ken LaMastus discussed
the information received from Boatmen's Trust Com-
pany regarding investment of all tobacco related stocks,
bonds and mutual funds, the Council approved the
following motions submitted by Dr. William Jones:
The AMS Council send a letter of commendation
to the President of the United States, Bill Clinton, and
the Commissioner of the Food and Drug Administra-
tion, David Kessler, for their leadership roles in the
fight to reduce teenage use of tobacco products and
the recognition of nicotine as an addictive drug con-
tained in tobacco that is responsible for the premature
death of over 400,000 United States citizens each year
and that copies of these letters be forwarded to the
Board of Trustees of the AMA.
The AMS Council instruct the Budget Committee
to carry out the divestment of tobacco related stocks,
bonds, and mutual funds contained in the portfolio of
the AMS, the AMS Pension Plan and MEFFA with
due consideration to the suggestions outlined in the
August 1, 1996, letter from Boatmen's Vice President
Pat D. Moon.
Any future investments of the AMS controlled
funds exclude the purchase of any tobacco related
stocks, bonds or mutual funds. The tobacco invest-
ment action taken be reported to the AMA Board of
Trustees and the American Medical News. These ac-
tions shall be reported to the AMS membership in the
next newsletter and in a future publication of The Jour-
nal of the Arkansas Medical Society and the report shall
indicate the AMS Council's encouragement of the
membership to take similar action in regard to their
individual investment portfolios.
Important Changes in Antitrust Enforcement
Policy for Physician Networks
On August 28, 1996, the U.S. Department of Jus-
tice (DOJ) and the Federal Trade Commission issued
their Statements of Antitrust Enforcement Policy in
Health Care (the "new guidelines"). The new guide-
lines revise older guidelines (the "old guidelines") by
removing barriers to the formation of physician spon-
sored health care delivery networks.
The Problems with the Old Guidelines
There were two major problems with the old guide-
lines. First, they limited physician networks to those
where the physicians assume substantial financial risk
similar to insurance risk, including capitation and sub-
stantial fee withhold arrangements. Such networks
require large amounts of capital to organize and skill
in managing insurance risk, which many physicians
do not have. Further, most states require that networks
contracting with self-insured employers obtain an in-
surance license, which requires substantial capital and
creates other problems for networks. Some states even
require a license when they contract with HMOs. Sec-
ond, they limited the size of physician networks, which
made it difficult for them to be competitive with net-
works organized by non-physicians. Patients want a
wide choice of physicians available, and it is difficult
to offer choice in a small network. This restriction may
have been more apparent than real, but it discouraged
the formation of networks.
Key Features of the New Guidelines
The new guidelines substantially resolve these
problems by expanding the options available to physi-
cians. These changes will benefit physicians in all kinds
of practice settings. For example: ^Physicians in solo
or small group practice without access to substantial
capital and management resources will be able to get
started in managed care by organizing fee for service
networks. “^Large group practices and medical faculty
practice plans that wish to expand their service and
geographic coverage by contracting with independent
physicians, IPAs, or other group practices will be able
272
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
to offer a wider array of products to managed care
plans and self insured employers. For example, they
will be able to offer fee for service PPO products as
well as capitated HMO products, and they will be able
to engage in direct contracting with self insured em-
ployers without triggering insurance regulations.
Fee for Service Networks May Be Organized
The new guidelines have two features which make
it possible for physicians to organize fee for service
networks that are legal and which can serve self-insured
employers and other customers. They include:
Fee for Service Networks with Clinical and Func-
tional Integration. Networks where the physicians are
paid on a fee for service basis by payors according to a
fee schedule that the physicians have agreed on, are
now legal provided that there is adequate clinical and
functional integration of the physicians in the network.
Such integration may consist of an active and ongoing
program to evaluate and modify practice patterns by
the network's physicians and create a high degree of
interdependence and cooperation among the physi-
cians to control costs and assure quality. This can be
shown by;
^Establishing mechanisms to monitor and control
utilization of health care services that are designed to
control costs and assure quality of care;
■^Selectively choosing network physicians who are
likely to further these efficiency objectives; and
■^The significant investment of capital, both mon-
etary and human, in the necessary infrastructure and
capability to realize the claimed efficiencies.
These networks do not qualify for a safety zone,
but are clearly legal if properly organized. Other forms
of integration where agreements on price are reason-
ably necessary to achieve the integration also may be legal.
Safety Zone for Fee for Service Networks Featur-
ing Substantial Financial Rewards or Penalties Based
on Utilization. A fee for service network is legal if the
member physicians will receive a substantial reward if
utilization goals are met OR a substantial penalty if
such goals are not met. It is not clear whether the
network must be subject to both a reward and a pen-
alty or if it is adequate if one or the other is in place.
The AMA believes that a reward only is sufficient if
the reward is substantial enough to motivate physi-
cians to attain it.
This allows fee for service networks to enter ar-
rangements where they are rewarded for controlling
utilization without assuming insurance risk. It enables
them to engage in direct contracting arrangements with
employers where they are rewarded for achieving sav-
ings without being engaged in the business of insurance.
Networks Can Be Larger than Safety Zone Size Limits
Under the old guidelines, physician networks had
to fall within size limits to qualify for a safety zone.
Exclusive networks, meaning networks where the
physicians agree to deal with health plans only through
the network and not to participate in any other net-
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work, were limited to no more than 20% of the physi-
cians in any given specialty in a market. Nonexclusive
networks, meaning networks where physicians were
free to deal independently with health plans or to par-
ticipate in other networks, were limited to no more
than 30% of the physicians. Some physicians were
advised that they should not organize networks larger
than the safety zone limits if they wanted to avoid the
risk of antitrust prosecution.
The new guidelines do not change the safety zone
size limits. However, they clarify that networks can
be substantially larger than the limits, and they also
provide guidance about when larger networks are le-
gal. The clarification says (at pg. 63 of the new guide-
lines): "The agencies emphasize that merely because a
physician network joint venture does not come within
a safety zone in no way indicates that it is unlawful
under the antitrust laws. On the contrary, such ar-
rangements may be procompetitive and lawful, and
many such arrangements have received favorable business
review letters or advisory opinions from the agencies."
The clarification refers to opinions of the DOJ and
FTC where networks as large as 50% of the providers
involved were approved. With regard to when larger
networks may be legal, the new guidelines describe
two scenarios. First, the new guidelines recognize that
nonexclusive networks in competitive markets are
unlikely to be in violation of the antitrust laws. In this
regard, the new guidelines say (at pg. 78):
"If, in the relevant market, there are many other
networks or many physicians who would be available
to form competing networks or to contract directly with
health plans, it is unlikely that the joint venture would
raise significant competitive concerns."
Second, the new guidelines say that if different
physicians in a network have different incentives, then
a large network is unlikely to raise concerns. For ex-
ample, if a network has a core group of physicians
that have invested substantial amounts in the network
and have an interest in seeing the network succeed as
a business, those physicians have a different interest
than other physicians with whom they contract to fill
out the network. The owner physicians have an in-
centive to control the costs to the network of the sub-
contracting physicians. This would be the case when
a large group practice contracts with independent phy-
sicians to expand the services it can offer or its geo-
graphic coverage.
The AMA believes that it is possible for physician
networks to have 50% or even more of the physicians
in a specialty in competitive markets where there are
many physicians that would be available to form com-
peting networks or many other networks, or if there
is a divergence of economic interests among the phy-
sicians in a network.
Networks That Negotiate Risk and Fee for Service
Arrangements Under the old guidelines, physician
networks that accepted insurance risk through capita-
tion arrangements were not allowed to negotiate with
the same payors over fee for service arrangements.
Therefore, if a payor wanted the same network to serve
its HMO product and its PPO product, the network
could negotiate capitation arrangements with the payor
for the HMO product but could not negotiate fee for
service arrangements for the PPO product. Under the
new guidelines, the network can negotiate both types
of arrangements. However, the management tools,
such as utilization review programs, used by the net-
work to control costs and assure quality must be ap-
plied to both types of arrangements.
More Kinds of Risk Are Included in the Definition of
Substantial Risk
In addition to the fee for service arrangements dis-
cussed above, the new guidelines expand the number
of arrangements that fall within the definition of sub-
stantial risk. Networks whose members share substan-
tial risk and fall with in safety zone size limits (20% of
physicians in any specialty for exclusive networks and
30% for nonexclusive networks) qualify for safety zones.
The new kinds of risk included include (a) percentage
or premium arrangements, (b) global fees, and the (c)
use of utilization targets with substantial rewards or
penalties (the latter arrangement is discussed above in
connection with fee for service arrangements).
A More Efficient Messenger Model
Networks where the physicians wish to operate
on a fee for service basis, but which do not have ad-
equate clinical and functional integration to be legal,
may operate provided that the physicians use the
messenger model to arrive at fee arrangements with
payors instead of collectively negotiating a fee sched-
ule. The messenger model was available under the old
guidelines but was cumbersome and inefficient to use.
The new guidelines allow the messenger model to be
much more efficient.
The messenger model is designed to allow the
physicians in the network to arrive at a fee schedule
with payors without the physicians agreeing among
themselves about what fee schedules they will accept.
This is done by having a messenger manage a process
whereby each of the physicians in the network arrive
at individual agreements with the payor, as opposed
to having a representative of the physicians negotiate
a fee schedule on behalf of all of the physicians.
Under the process in the old guidelines, the mes-
senger communicates with each physician individu-
ally about what fee range the physician is willing to
accept, then aggregates the information without shar-
274
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
ing it with the physicians, and then presents the in-
formation to payors. Any payor may then make an
offer to the physicians in the network, and the mes-
senger relays that offer to the physicians. Each physi-
cian then makes a unilateral decision about whether
to accept the offer — the messenger may not tell any
physician about whether other physicians will accept
the offer, and cannot influence the physician's deci-
sion about whether to accept it.
The new guidelines add the following features to the
messenger model:
* Each physician may give the messenger author-
ity to accept contracts from payors that are within the
limits of a free range that the physician is willing to
accept.
* The messenger may develop a schedule show-
ing what percentage of physicians in the network
would accept offers at various fee levels.
* The messenger may accept the offer on behalf of
any physician who has given the messenger authority
to accept offers within the fee range offered by the
payor. The messenger may also accept offers on be-
half of any physician that are better than any offer
previously accepted by that physician.
* The messenger may provide objective informa-
tion to physicians in the network about a contract of-
fer made by a payor, such as the meaning of terms
and how the offer compares to offers made by other
payors.
Business Review Letters and Advisory Opinions
The new guidelines continue a procedure that
enables physicians to obtain opinions from the DOJ or
FTC about the legality of specific network proposals
before they are organized. The agencies have commit-
ted to respond to requests for opinions within 90 days
of the receipt of all relevant information.
Conclusion
The new guidelines include other positive features
as well. They provide a rich source of tools for physi-
cians to form different kinds of networks, and there
are now may options open to physicians to meet the
needs of their markets in a realistic and practical fash-
ion. Because of the complexity of the guidelines, phy-
sicians should be aided by experienced counsel as they
develop networks.
Physician Biographical Information Now on
AM A Web Site - http://www.ama-assn.org
All 650,000 U.S. physician biographies up on
the Internet
For every year he has been in practice, gastroen-
terologist Richard Corlin, M D., has paid up to $8,400
annually for a simple listing in the Yellow Pages with
his name, address and phone number. Today, Dr.
Corlin has his entire medical biography up on the
AMA's Internet Web site, at no cost.
AMA's new program, AMA Health Insight, con-
tains both the new patients' medical "Reference Li-
brary" and a new physician information database called
"AMA Physician Select."
The AMA database, the most comprehensive list-
ing of all U.S. physicians, lists a physician's educa-
tion, residencies, board certification and other signifi-
cant biographical information available. Patients can
search the database by physician name, location or
specialty.
"Patients can now pop-up on the Internet or head
to the public library and find a biography on their phy-
sician in a matter of seconds," said Richard Corlin,
MD., speaker of the AMA House of Delegates. "You
also can search your town by specialty and find a list
of all the licensed physicians in the area. This is a great
tool for members of the public seeking the best physi-
cians for themselves and their families."
AMA Physician Select
Although many local medical societies offer simi-
lar on-line search services listing member physicians,
AMA Physician Select is the first nationwide database
of all licensed physicians available to the public.
Searches can be conducted by 23 major specialties and
150 subspecialties, and by city, zip code, state or by
name. AMA Physician Select provides the physician's
name, address, phone number, gender, medical
school, all residency and internship information, spe-
cialty board certification and AMA membership.
AMA Patient Reference Library
The AMA Patient Reference Library contains in-
formation about the AMA and the medical profession
and a link to information and resources on diseases,
such as the JAMA/HIV AIDS Information Center. The
HIV Center features clinical updates, daily news and
information on social and policy questions related to
AIDS, under the direction of JAMA staff and an edito-
rial board of leading HIVIAIDS authorities.
AMA Members Receive "Expanded Web Site"
All AMA members are offered an "expanded web
page site" to list additional practice information, in-
cluding practice philosophy, health plans accepted,
hospital privileges, group practice affiliations, personal
information, practice hours, and even a photo. All
AMA members are also identified in the database by
the AMA logo, as are recipients of the AMA Physician's
Recognition Award for continuing medical education.
Volume 93, Number 6 - November 1996
275
"We expect 30 to 50 percent of patients to use the
Internet at home or in local libraries to find out more
about their physicians," said Corlin. "The expanded
web pages are much more than a yellow page ad. It's
like a brochure placed in the hands of thousands of
potential patients."
Only AMA members are eligible for the "expanded
web page" listing, although AMA's Corlin jokes that
any potential AMA member can purchase an expanded
web page for $425 — the price of AMA membership.
"They can get the expanded web page and all the other
benefits of membership for $425 annually, less than
the monthly cost of that Yellow Page ad."
The AMA launched its award-winning site on the
Internet in August of 1995 and includes clinical ab-
stracts and articles from the lournal of the American
Medical Association and AMA's nine specialty jour-
nals. All press releases, statistics and award-winning
American Medical News summaries are on the AMA's
web page, along with a data base of 7,000 approved
medical residency programs for graduating medical
students. In addition, all state, county and specialty
medical societies with existing home pages are accessible
through to the AMA's web page. More than 2.5 million
visits to the AMA web site were logged in the last year.
AMA has maintained a listing of all physicians
licensed and educated in the United States since 1906.
The AMA has opened that database to the public "to
help patients weigh their options and find the best
physicians for their needs," according to Corlin.
"AMA Physician Select is revolutionary. Never
have patients been able to gather so much information
on their physician at the click of a computer mouse,"
said Corlin. "Our patient Reference Library promises
to do the same for all of those looking for the most
up-to-date, reliable information on a broad spectrum
of conditions."
The AMA database includes only actively licensed
physicians. Neither will liability awards against phy-
sicians be made available, according to Corlin. "It's
impossible to interpret such information," he said. "Un-
fortunately it can be the most skilled physicians with
the sickest patients who find themselves in court, and
the average obstetrician is sued twice every 10 years,
regardless of professional competence."
PHYSICIANS:
OUTSTANDING PROFESSIONAL AND
PERSONAL OPPORTUNITIES.
The Army Medical Department not only offers physicians an out-
standing working environment, but an outstanding living environment
as well.
Today’s volunteer Army places great emphasis on quality of life
issues such as family support, and safe and well-maintained living
spaces. You’ll find military bases and the military community tend to
represent an extremely achievement-oriented population, concerned
with basic family values.
On the professional side you’ll benefit, too. Here is how Army
Medicine can benefit you:
■ no malpractice insurance
■ state-okhe-art facilities and equipment
■ unparalleled training programs
■ 30 days of paid annual vacation
If you want to talk to an Army physician or visit an Army hospital
or medical center, our experienced Army Medical Counselors can assist
you. Call:
800-USA-ARMY
ARMY MEDICINE. BE ALL YOU CAN BE:
276
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
AMS Newsmakers
Dr. M. Carl Covey,
a physician of pain
medicine in Fayette-
ville, recently attended
the 8'*' World Congress
of the International As-
sociation for the Study
of Pain in Vancouver,
British Columbia.
Dr. Mark Landis,
a family physician in
Pocahontas, has made
three trips to Cambodia
in the past 18 months
to offer medical care to the orphans. Dr. Landis,
founded an organization named First Serve the Earth's
People, or First S.T.E.P. The non-governmental, non-
profit organization seeks to work with the Cambodian
government in providing more and better care for the
nation's street children.
Dr. Kerry F. Pennington, of Warren, was recently
named the Arkansas Eamily Doctor of the Year by the
Arkansas Academy of Family Physicians. Fie will be
nominated by the Arkansas Academy for the 1997 Na-
tional Family Doctor of the Year which will be pre-
sented in October 1997.
Dr. Hampton Roy, a Little Rock opthalmologist,
has written and recently published a book titled "Ocu-
lar Differential Diagnosis, 6"’ Edition." The book has
19 contributors from throughout the world.
Dr. Robert B. White, a Paragould internist, was
recently named President of the American Heart
Associaiton's state affiliate where he has been an ac-
tive member for several years.
The Physician's Recognition Award is awarded
each month to physicians who have completed accept-
able programs of continuing education. Recipients for
the month of September 1996 are: Jeffery D. Angel,
Batesville; Paul R. Neis, Mountain Home; Franklin D.
Roberts, Magnolia; and Linda N. Teal, Mountain
Home.
Send your accomplishments and photo for
consideration in AMS Newsmakers to:
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
M. Carl Covey, M.D.
Other than this...
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AMBULANCE
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There are only two better vehicles for reaching
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Volume 93, Number 6 - November 1996
277
f ff.injrF7C}Ty
The 1996 E-Class: Spacious interior. Stunning performance. No wonder you don’t want to be reached. Mercedes-Benz
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charges, Insurance, optional equipment, certificate of compliance or noncompliance fees, and finance charges. Prices may vary by dealer.
E320 Sedan shown at MSRP of $43,500. ©1995 Authorized Mercedes-Benz Dealers
Mark Michael Allard, M.D.
PROFESSIONAL INFORMATION
Specialty: Orthopaedic Surgery
Years in Practice: A little over three months
Office: Siloam Springs
Medical School: UAMS, 1991
Intemshipl Residency: UAMS, 1992/1996
Honors! Awards: Alpha Omega Alpha Medical Honor Society
Member and in Spring of 1996 was voted Outstanding Chief Resident
Teacher by UAMS Department of Orthopaedic Surgery
PERSONAL INFORMATION
Spouse: Julie
Children: Son, Michael, 2 years old and daughter, Grace, 11 months old
Date/Place of Birth: September 1, 1964, in Chicago, Illinois
Hobbies: Golf, bass fishing, softball, reading John Grisham novels
THOUGHTS & OTHER INFORMATION
Worst habit: Being late
Best habit: Staying in a good mood
Favorite junk food: Little Debbies
Most valued material possession: Our new home
The turning point of my life was when: I met my wife
Nobody knows I: Quit chewing tobacco three years ago
Favorite vacation spot: Lucerne, Switzerland
One goal I haven't achieved yet: Bogey golf
One goal I am proud to have reached: Fatherhood
Favorite Childhood Memory: Summer vacations driving cross-country
When I was a child, I wanted to grow up to be: A football player or an orthopaedic surgeon
One of my pet peeves: Snobs
First job: Newspaper carrier (age 12)
Worst job: Weekend janitor at my college dorm
One word to sum me up: Optimistic
My life philosophy: Work hard, take good care of my family
and my patients, and good things will happen.
If you would like to appear in New Member
Profile or Member Profile, contact Tina Wade
at AMS at (501 ) 224-8967 or 1 -800-542-1058.
Volume 93, Number 6 - November 1996
279
I-'
^ 1'
c
Ol
;S!
J^rofessional J\otection Sxclusively since /8S9
To reach your local office, call 800-344-1899.
Scientific Article
Anaphylaxis: Multiple Etiologies - Focused
Therapy
John M. James, M.D.*
Abstract
Anaphylatic reactions are severe, generalized clini-
cal reactions. They can occur with or without warn-
ing, progress rapidly from isolated to systemic symp-
toms, and may in some cases result in death. Esti-
mates in the United States have projected that ana-
phylaxis can occur in approximately one in every 3000
hospitalized patients, and may be responsible for more
than 500 deaths annually. This review will present
information related to the epidemiology, pathophysi-
ology, diagnosis and treatment of anaphylactic reac-
tions. In addition, key prevention measures will be
discussed.
Introduction
The term anaphylaxis actually means "backward
protection." This word has its origins from the Greek:
ana = backward, and phylaxis = protection. Fortier
and Richet introduced the term in 1902 to describe a
paradoxical clinical observation occurring with an ex-
perimental protocol immunizing dogs against a toxin
derived from the sea anemone. An increased sensitiv-
ity and even death was observed when these animals
were subsequently injected with smaller doses of the
toxin. For these initial landmark scientific investiga-
tions regarding anaphylaxis, Richet was eventually
awarded the Nobel Prize in Medicine.
Classically, anaphylaxis represents a rapid, gener-
alized, and often unanticipated immune-mediated
event that occurs after exposure to certain foreign sub-
stances in previously sensitized persons.’ This systemic
reaction can affect virtually any organ in the body, but
most commonly involves the following systems: cuta-
neous, gastrointestinal, pulmonary, circulatory, and
neurological. In contrast, anaphylactoid reactions rep-
resent a clinically indistinguishable syndrome from
anaphylaxis that are not mediated by IgE antibody.
These reactions do not necessarily require a previous
exposure to the inciting substance. This review will
* John M. James, M.D., is Assistant Professor of Pediatrics at
Arkansas Children's Hospital Research Institute and UAMS.
Volume 93, Number 6 - November 1996
focus on the epidemiology, pathophysiology, clinical
features, diagnosis, treatment and prevention of ana-
phylaxis. Unless stated otherwise, specific information
in this review will directly relate to anaphylaxis, un-
less a particular anaphylactoid reaction needs to be
highlighted. !
Epidemiology jij
A recent review article highlighted the epidemiol- j:|
ogy of anaphylactic reactions.’ While there are no reli-
able prospective data in this area, the incidence of h
anaphylaxis does appear to be increasing. Rising envi- 'jl
ronmental exposures may be responsible for this trend. , j
As stated above, estimates in the United States have
proposed that anaphylaxis can occur in as many as 1
in every 3000 hospitalized patients, and be respon-
sible for hundreds of deaths annually. Rates of ana- jj'
phylaxis appear to be similar in patients with and with-
out atopic (allergic) histories. Age, gender, race, occu- ij
pational and geographic factors do not appear to pre- )
dispose an individual to anaphylaxis. Patients with
asthma, however, do appear to be more susceptible to
life-threatening complications from anaphylactic reac-
tions.
Of the common causes of anaphylaxis, penicillins
are responsible for approximately 1 case per 10,000
administrations and anaphylaxis following insect stings
affect 0.4-1% of the general population. As many as
40-50 deaths per year occur in the United States as a
result of insect sting-induced anaphylaxis. In terms of
anaphylactoid reactions, radiocontrast agents are re-
sponsible for approximately 1 case per 5000 exposures.
Recurrence risks of anaphylaxis and anaphylactoid
reactions have been examined with the following re-
sults: penicillins: 10-20%, insect stings: 40-60%, and
radiocontrast agents: 20-40%.
In 1989, Sorensen published a retrospective review
of 20 cases of anaphylactic shock occurring outside of
a well-defined hospital referral area in Europe.^ There
were 3.2 cases per 100,000 inhabitants per year with
an estimated mortality of 5%. The identified precipi-
tating agents were as follows: antimicrobials (50%) in-
281
g
A
eluding penicillins and sulfa drugs, insect stings (40%)
and foods (10%). In terms of anaphylactic shock oc-
curring within a hospital setting, a drug surveillance
program reported 3 reactions per 10,000 patients.'^ Spe-
cific incidence rates were determined as follows: peni-
cillins 15-40 reactions per 10,000 patients, radiocontrast
media one reaction per 600 patients, blood products
one reaction per 400 patients and anesthetics one re-
action per 20,000 patient exposures.
Potential Mechanisms
Certain pathophysiological events provide the
foundation for the clinical signs and symptoms ob-
served during anaphylactic reactions.’ Most impor-
tantly, activation of mast cells is the central patho-
physiological event underlying these reactions. These
cells are located in multiple sites throughout the body,
especially in places where clinical symptoms of ana-
phylaxis are observed including the skin, the gas-
trointestinal tract, and respiratory system. A variety
of mast cell mediators, both pre-formed and
newly-generated, have been identified and are respon-
sible for the vasodilatation, vascular permeability,
mucus secretion and bronchospasm typically involved
in an anaphylactic reaction. Following mast cell acti-
vation, the cell's granules coalescence, migrate to the
cell membrane surface and their contents are released
into the circulation to be distributed to various organ
systems. These mediators give rise to the specific clini-
cal symptoms observed during anaphylaxis.
As mentioned above, there are both pre-formed
and newly synthesized mast cell mediators (Table I).’"”'
Of the preformed mast cell mediators, histamine is
the most well known. Tryptase is another pre-formed
mediator that has generated interest over the past ten
years.'* This proteinase is specific to mast cells and is
not found in basophils or eosinophils that may partici-
pate in allergic inflammation. Tryptase has a prolonged
presence in the peripheral blood circulation with a
half-life of many hours, as opposed a half-life of min-
utes for histamine. Finally, tryptase can be measured
by an immunoassay. Therefore, tryptase has been pro-
posed as a marker of mast cell activation and can be
used in the laboratory evaluation of suspected ana-
phylactic reactions.'* Chymase, heparin, and chon-
droitin sulfate are other preformed mast cell media-
tors involved in anaphylactic reactions. Again, all of
these preformed mast cell mediators reside in mast
cell granules and can be released immediately upon
activation of this cell. These mediators are largely re-
sponsible for the immediate symptoms of anaphylaxis
including vasodilatation, edema, mucous secretions,
and bronchospasm.
In contrast, there are newly-synthesized mast cell
Table I:
Mediators of Anaphylactic Reactions
Preformed mast cell mediators
Histamine
Tryptase
Chymase
Heparin
Chondroitin sulfate
Newly-generated mast cell mediators
Prostaglandins
Leukotrienes
Platelet activating factor
mediators that are important to the pathophysiologi-
cal process of anaphylaxis (Table I).*'"’ Prostaglandins,
leukotrienes and platelet activating factor are examples
of mediators in this group. Because these mediators
need to be actively generated, they most likely propa-
gate the anaphylactic episode and the late phase aller-
gic reaction.
Several major mechanisms have been proposed for
anaphylaxis (Table II). First and foremost, IgE-mediated
reactions have been shown to be a mechanism for mast
cell activation and subsequent anaphylaxis.’ Suscep-
tible atopic individuals form specific IgE antibodies to
potential allergens. These IgE antibodies bind to high
affinity receptors on the surface of tissue mast cells
located in a variety of organs including the skin, intes-
tinal tract, lung. Subsequent exposure to the respon-
sible allergen (e.g. hymenoptera venoms, antimicro-
bials, foods) results in release of the specific mediators
of anaphylaxis. These mediators initiate and propa-
gate the anaphylactic reaction.
Activation of the complement cascade is another
potential mechanism resulting in anaphylaxis.’ Cer-
tain biological proteins (e.g. immune complexes, hu-
man proteins) and dialysis membranes can generate
specific complement proteins, which have been des-
ignated anaphylatoxins, that bind complement recep-
tors on the mast cell surface. This results in activation
of the mast cell and the release of mediators of ana-
phylaxis mentioned above.
Another mechanism of anaphylaxis involves the
direct activation of mast cells.’ This process is inde-
pendent of IgE antibodies or the complement cascade
and is traditionally labeled as an anaphylactoid reac-
tion. Hyperosmolar solutions such as radiocontrast
dyes and vancomycin are the best examples of agents
that directly activate mast cells. Finally, there are other
undefined or idiopathic mechanisms of mast cell acti-
vation that result in anaphylaxis. Aspirin, and
exercise-induced anaphylaxis are included in this category.
282
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table II: Mechanisms of Anaphylaxis
Reaction Mechanism
Agents
Examples
IgE-mediated:
venoms
Hymenoptera
antibiotics
penicillins, sulfas
foods
peanut, egg, milk,
seafood, tree nuts
latex
catheters, surgical
gloves
Complement activation and
anaphylatoxins:
human proteins
gamma globulin,
insulin
dialysis
dialysis membranes
Direct activation of
mast cells:
hypertonic
solutions
radiocontrast dyes
drugs
vancomycin
Undefined or Idiopathic:
NSAID=^
aspirin,
indomethacin
anesthetics
exercise
lidocaine
*non-steroidal anti-inflammatory drugs
Clinical Signs and Symptoms
Because anaphylaxis is a generalized reaction, a
wide variety of clinical signs and symptoms may be
observed.’-® The most common symptoms involve the
skin including: urticaria, angioedema and pruritus with
or without a specific skin rash. Another common sys-
tem involved is the gastrointestinal system including:
nausea, vomiting, abdominal cramping and diarrhea.
Common respiratory symptoms include: rhinitis, tear-
ing, sneezing, laryngoedema, stridor, dyspnea, cough
and wheezing. Finally, specific cardiovascular symp-
toms are typically manifested by dizziness, hypoten-
sion and syncope. Rarely, seizures have been observed
during anaphylaxis.
Urticaria and angioedema are the most common
reported clinical findings in up to 88% of cases of ana-
phylaxis.® Respiratory symptoms are also very com-
mon as noted in approximately 50% of patients. Car-
diovascular and gastrointestinal symptoms are the next
two most common systems involved in at least
one-third of the patients. Other symptoms such as
headaches, pruritus without a skin rash, and seizures
are observed in a minority of patients. In summary,
generalized symptoms involving the skin, gastrointes-
tinal tract, lungs and cardiovascular system are the
most helpful clinical indicators of a possible anaphy-
lactic reaction.
On a more serious note, ana-
phylaxis may in some instances be
responsible for fatalities. An article
from the Journal of Forensic Science
reviewed 43 fatalities from anaphy-
laxis occurring over a 15 year pe-
riod.'’ Eighty-six percent of the cases
had a very rapid symptom onset,
which typically occurred within 20
minutes, and 51% of the patients
died within one hour of the initial
presenting symptoms. The authors
emphasized that there were key
clinical findings, such as respiratory
and cardiovascular symptoms, in
the fatalities from anaphylaxis. Fi-
nally, postmortem examinations
revealed common respiratory tract
pathology including airway edema
and obstruction, as well as hemor-
rhage into the airways.
Specific Agent of
Anaphylaxis
A multitude of different agents
have been implicated in anaphylac-
tic reactions (Table 11).’® Among
these agents, antibiotics, such as
penicillin, are frequently the cause of anaphylaxis and
these reactions are the result of IgE-mediated sensitiv-
ity. Most health care providers are familiar with peni-
cillin allergy and have observed these reaction in their
clinical practice. The parenteral route is more immu-
nogenic than the oral route, but all routes of adminis-
tration can ultimately lead to anaphylaxis. There ap-
pears to be an increased severity of reactions, how-
ever, in patients who are on beta blockers. The reason
for this is that if these patients develop respiratory
symptoms, they are more difficult to manage. Finally,
approximately 10% of penicillin-induced anaphylaxis
are fatal with an estimated 400-800 deaths occurring
annually in the United States.
Hypersensitivity reactions to venom from insects
in the hymenoptera order are another major cause of
IgE-mediated anaphylactic reactions.® The earliest case
of anaphylaxis was thought to have been recorded in
ancient Egypt in the year 2060 B.C. A pharaoh was
depicted in hieroglyphics as having died from a wasp
sting. A recent review noted that insect venom allergy
is probably the most common cause for anaphylactic
reactions.’ The insects in the hymenoptera order in-
clude honey bees, wasp, yellow-jackets, hornets and
fire ants. Of these, the honey bee will typically leave a
stinger at the injection site, providing a clue as to the
identity of the offending insect. While approximately
Volume 93, Number 6 - November 1996
283
3% of the general population is sensitized to insect
venom, only 0.4 to 1% of the population will experi-
ence an generalized anaphylactic reaction following an
insect sting. There are approximately 40-50 deaths per
year in the United States from insect sting anaphy-
laxis. Therefore, this can be a very serious clinical prob-
lem if not properly treated and prevented.
One study reviewing a large group of fatalities fol-
lowing insect stings has been highlighted. ’This was a
retrospective review of 50 fatalities and 100 non-fatal
cases. The symptom onset was typically less than 30
minutes from the sting. Over 50% of the victims died
within the first hour of the sting. The major sites of
pathology included the respiratory tract, cardiovascu-
lar, and neurological systems. The timely administra-
tion of epinephrine appeared to be a crucial manage-
ment factor preventing patients from developing fatal
anaphylaxis.
Foods are another major cause for IgE-mediated
anaphylaxis.’ For example, peanuts are notorious for
not only being a major cause of these reactions, but
allergic sensitivity to this food is typically life-long.
Tree nuts, shellfish, cow milk and eggs are other com-
mon food allergens that can precipitate anaphylaxis.
A recent review of the literature identified several fea-
tures related to food-induced anaphylaxis.’ These re-
actions usually occur in individuals with previous his-
tories of atopic diseases such as atopic dermatitis, al-
lergic rhinitis, and asthma. The onset of symptoms
are typically within 30 minutes following food inges-
tion. Interestingly, asthmatics may be more suscep-
tible to life-threatening reactions, because these pa-
tients develop respiratory symptoms that are more
difficult to manage during the actual anaphylactic
event.
As previously mentioned, deaths following
food-induced anaphylaxis can occur. Two retrospec-
tive studies have been reviewed, one from the Mayo
Clinic and one from Johns Hopkins Hospital.’ Over a
short observation period, these two centers identified
13 fatalities and 7 near-fatal cases from their respec-
tive referral areas. Common features have been identi-
fied from these two investigations. Prior histories of
anaphylaxis to the incriminated food were present in
these patients indicating a prior knowledge of allergic
reactions following food ingestion. The ingestion of
the food was typically in an accidental fashion, sug-
gesting the food allergen was hidden in the ingested
food. Moreover, the patients were typically away from
home, either in a day care, school setting or at a pic-
nic, when the anaphylactic episodes occurred. Most
importantly, the patients who had fatalities lacked the
immediate use of epinephrine to manage the anaphy-
lactic reaction.
Allergen immunotherapy and skin testing with
allergen extracts are another cause of IgE-mediated
284
anaphylaxis. Several published reports from 1973 to
present have examined this issue. ^ These investiga-
tions have identified six deaths following allergen skin
testing. Of these deaths, five patients died following
intradermal skin testing before they were subjected to
any other method of skin testing. Typically, patients
undergo epicutaneous or skin prick skin testing be-
fore intradermal testing is performed. Fifty-one deaths
from allergen immunotherapy or "allergy shots" have
been identified from 1973 to present.^ These reactions
typically onset within 30 minutes. Key risk factors have
been identified including errors in using the wrong
immunotherapy extract bottle, which may contain an
inappropriate concentration, or a new immunotherapy
vial that has recently been re- formulated. Patients re-
ceiving immunotherapy with symptomatic asthma, as
well as patients on beta blockers are considered pa-
tients at higher risk for developing anaphylaxis after
immunotherapy injections. These patients may expe-
rience more severe anaphylactic reactions with diffi-
cult to manage respiratory symptoms. The American
Academy of Allergy, Asthma and Immunology has
provided recommendations reinforcing that patients
receiving immunotherapy should receive these shots
in the clinical setting, not at home, where the patient
can be treated immediately for anaphylaxis if neces-
sary. In addition, this statement recommends obtain-
ing peak flow measurements before and after immu-
notherapy in patients with asthma. These recommen-
dations should ensure that patients with asthma are
not in a symptomatic phase of their disease before
immunotherapy injections are administered.
There has been a recent interest in latex and
latex-containing products as a new agent causing
IgE-mediated anaphylactic reactions.’ Latex is com-
monly found in commercial brands of surgical gloves,
some forms of IV tubing, penrose drains, certain
nipples for infant bottles, and stoppers on some phar-
maceutical bottles. A recent review highlighted ana-
phylactic reactions to latex and latex-containing prod-
ucts.** The allergen in latex comes from a plant product
derived from the rubber tree, Hevea brasiliensis . The
common risk factors for sensitization to latex include
the following: frequent use of latex-containing prod-
ucts, patients with prior or current hand dermatitis
especially while wearing latex-containing gloves, and
the presence of a prior atopic disease (e.g. allergic rhini-
tis, atopic dermatitis). Moreover, patients with myelo-
dysplasia or spina bifida constitute an unique subset
of patients that have been shown to have sensitization
to latex. Up to one-third of these patients may become
sensitized, most likely because of their frequent expo-
sure to these products in the form of urinary cath-
eters, neurosurgical shunting tubing, and frequent
exposures to latex during surgical procedures. Esti-
mates of 6-10% of hospital personnel have been found
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
to be sensitized to latex and a significant percentage of
these individuals will have allergic symptoms includ-
ing generalized anaphylaxis upon subsequent expo-
sures to latex. For these reasons, many hospitals have
developed specific policies for latex-allergic individu-
als. The aims of these policies are to prevent sensitiza-
tion, exposure and ultimately allergic reactions to latex.
The intravenous administration of immune gamma
globulin and plasma products, as well as certain dialy-
sis membranes are agents that may activate the comple-
ment system.^ This activation leads to the generation
of specific complement proteins that bind to receptors
on the mast cell surface, activate this cell, and may in
some cases lead to anaphylaxis.
Several agents can directly activate the mast cell
and precipitate anaphylactoid reactions.’ Again, these
reactions are not mediated by specific IgE antibodies.
Hyperosmolar solutions, mainly radiocontrast dyes and
mannitol, are the best examples. In addition, opiates.
Vancomycin, and muscle depolarizing drugs (e.g. suc-
cinylcholine) would also be included here. A recent
publication reviewed a large group of reactions of
radiocontrast dye and found that the reactions are typi-
cally unpredictable and independent of the dose that
is administered.’ As mentioned previously, the exact
cause for these reactions is unknown. The use of con-
trast agents with lower osmolality appeared to decrease
the future risk anaphylaxis when these patients needed
radiocontrast dye. Finally, pre-treatment of these pa-
tients with antihistamines and even steroids have been
shown in some cases to prevent future reactions with
radiocontrast dye.
Anaphylactic reactions to aspirin and non-steroidal
anti-inflammatory drugs occur secondary to a pre-
sumed abnormality of arachidonic acid metabolism.’
Some investigators have proposed that this metabolic
abnormality may generate haptens that bind to serum
proteins. These complexes ultimately trigger an ana-
phylactic reaction upon future exposure to these
agents. This proposed mechanisms needs to be con-
firmed in future investigations. Patients experiencing
these reactions are otherwise normal and non-atopic,
and they characteristically react to only one
non-steroidal or aspirin-containing product. Occasion-
ally, these patients will cross-react to a multiple drugs
in this class, but usually an alternative drug out of this
group can be administered without adverse clinical effects.
Finally, there are anaphylactic episodes for which
the specific etiology remains unknown.’ ’ Idiopathic
anaphylaxis typically involves patients in their teens
or early 20's who have recurrent episodes of anaphy-
laxis with undefined etiologies. These reactions are
typically recurrent with a high risk of having similar
episodes in the future. These patients are usually
treated with prophylactic antihistamines and/or ste-
roids to prevent future episodes. Exercise-induced
anaphylaxis has been described in the literature as well
as food-dependent exercise-induced anaphylaxis. In
the food-dependent form, the patients have to have
both of these events together to experience an ana-
phylactic episode. A severe form of cholinergic urti-
caria can present with anaphylaxis. Dr. Virant recently
reviewed and compared a variety of episodes of ana-
phylaxis with unknown causes. First, cholinergic urti-
caria, which usually involves an isolated rash with small
pin-point hives in a discrete distribution on the body,
can proceed to anaphylaxis. These patients can expe-
rience wheezing, but they rarely develop hypotension.
Episodes are triggered by events that lead to a rise in
the core body temperature such as exposure to heat,
stress, exercise and anxiety. In contrast
exercise-induced anaphylaxis typically presents with
a much larger urticarial rash following exercise. Stri-
dor, laryngoedema, and hypotension are common clini-
cal findings in this condition.
Diagnosis
The medical history remains the most important
clinical routine in the work-up of anaphylactic reac-
tions.’’The major goal of the history is to establish a
temporal association between a suspected etiologic
agent and the actual clinical episode of anaphylaxis.
The history should search for an association of typical
signs and symptoms (e.g. cutaneous, gastrointestinal,
respiratory and cardiovascular symptoms) with the
exposure to a suspected agent(s). Remember that ana-
phylaxis is a generalized reaction and multiple pre-
senting symptoms are common. Moreover, the onset
and reproducibility of the specific symptoms should
be noted. In terms of the laboratory confirmation of
these reactions, there are few things to pursue. While
no serological tests accurately confirm anaphylaxis, a
few studies can be useful in the work-up. Skin testing
or blood (RAST) testing for allergens can, in some in-
stances, be useful. Properly performed skin prick test-
ing for a particular agent responsible for IgE-mediated
reactions such as penicillin, insect venom and foods
can be helpful in the diagnosis. Skin testing for aller-
gens, however, should not be performed if the patient
has a severe convincing history of anaphylaxis to a
given allergen. In addition, clinical challenges under
direct medical supervision can be performed in certain
situations, but they are typically performed in research
settings. ’These should be performed in a setting where
anaphylaxis can be managed immediately if it occurs.
Finally, serological markers for anaphylaxis have re-
cently been proposed.'’ Serum tryptase levels can be
determined by immunoassays.
Because this mast cell protease has a long half-life
in the serum, its elevation in a clinical setting suggestive
of anaphylaxis can be useful in the confirmation of
this reaction.
Volume 93, Number 6 - November 1996
285
Table III:
Differential Diagnosis of Anaphylaxis
and Anaphylactoid Reactions
A. Acute respiratory decompensation
1. severe asthma attacks
2. foreign body aspiration with obstruction
3. pulmonary embolism
4. hereditary angioedema
B. Loss of consciousness
1. vasovagal syncope
2. seizure disorders
3. myocardial infarctions and/or arrhythmias
C. Disorders resembling anaphylaxis
1. systemic mastocytosis
2. carcinoid syndrome
3. restaurant syndrome (monosodium
glutamate)
D. Non-organic diseases
1. panic attacks
2. vocal cord dysfunction
3. Munchausen's syndrome
Differential Diagnosis
The differential diagnosis of anaphylaxis includes
a variety of clinical conditions (Table Acute res-
piratory decompensation from severe asthma at-
tacks, foreign body aspiration with obstruction, and
pulmonary embolism can present with respiratory
symptoms suggestive of anaphylaxis. Hereditary an-
gioedema usually presents with severe swelling of
mucosal membranes, upper airway, lips and tongue,
as well as gastrointestinal symptoms such as cramp-
ing and diarrhea. These patients may have a family
history of hereditary angioedema, but they typically
do not have pruritus and urticaria that is typically ob-
served in allergic reactions. Syndromes that include a
loss of consciousness, especially vasovagal syncope,
should be considered in the differential diagnosis of
anaphylaxis. This syndrome typically has a sudden
onset and involves bradycardia and diaphoresis. It
usually does not involve tachycardia or urticaria. Oc-
casionally, seizure disorders, myocardial infarctions
and/or arrhythmias will initially present in a similar
fashion to anaphylaxis. Finally, there are a group of
disorders that resemble anaphylaxis. Mastocytosis and
carcinoid syndrome are both very rare disorders that
can present with cutaneous symptoms resembling
anaphylaxis. "Chinese restaurant" syndrome is an
abnormal physiologic response of the body to mono-
sodium glutamate, which is a common food additive.
This food intolerance reaction is often misinterpreted
as an allergic or anaphylactic reaction. Finally,
non-organic diseases such as panic attacks, vocal cord
dysfunction and Munchausen's syndrome can, in some
instances, present with symptoms resembling anaphy-
lactic episodes.
Treatment and Prevention
The treatment and prevention of anaphylaxis
should provide a comprehensive plan for the affected
patient (Table IV). First, identifying and eliminating
the offending agent responsible for anaphylactic epi-
sodes is the foundation of any successful therapy plan.
Unfortunately, this is not always an easy task. If the
offending agent is identified, the patient and family
need to be educated about preventing future expo-
sures. In the event an anaphylactic episode is encoun-
tered, an emergency system (#911) should be activated
to transfer the patient to a health care facility, if neces-
sary. The extent and severity of the reaction should be
rapidly assessed and basic life support measures un-
dertaken. The main focus should be on the airway,
the monitoring of vital signs and systemic perfusion.
In addition, the rapid and judicious use of epineph-
rine cannot be overemphasized for this is the corner-
stone of therapy for acute anaphylaxis. Administra-
tion of epinephrine rapidly reverses the symptoms of
anaphylaxis and appears to be the key to preventing
fatalities.’ Supplying this medication in the form of pre-
loaded autoinjecting syringes has been an extremely
helpful to patients. There devices typically contain a
single dose of epinephrine, and they can be kept at
home, school, and work. Demonstrators are available
to educate patients on the proper use of these devices.
Other key management issues include rapid volume
resuscitation if necessary. Antihistamines can be ad-
ministered for the acute management of urticaria and
pruritus, in some cases, for protracted cases of ana-
phylaxis. These medications have also been utilized
as a prophylactic measure in some patients with idio-
pathic anaphylaxis. There are certain conditional agents
that are important including vasopressors to support
blood pressure, treatment of bronchospasm in patients
who are having respiratory distress and glucagon in-
fusions in patients on beta blockers who experience
anaphylaxis. Glucagon appears to be very helpful in
supporting the cardiovascular system in these patients
and supporting them during the anaphylactic episode.
Corticosteroids are not really useful in the acute man-
agement of anaphylaxis, but they may be useful in
preventing the late phase allergic reaction. They can
also be useful in the prevention of anaphylaxis in some
patients with idiopathic anaphylaxis.
There are a variety of education materials avail-
able to patients who have experienced anaphylactic
reactions.^ Specific pamphlets have been published
286
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table IV: Treatment and Prevention of Anaphylaxis
A. General measures:
1. Identify and eliminate the offending agent
2. Develop plan to prevent future exposures
B. Specific treatment measures:
1. Activate emergency medical system (#911)
2. Assess airway, breathing and circulation
3. Transfer the patient to a health care facility
4. Administer initial medications as indicated:
a. epinephrine: 0.2-0. 5 cc of 1:1000 dilution, SQ
b. antihistamines: 12.5-25 mg IM or orally
c. oxygen: 40-100%
d. albuterol: 0.3 cc (0.5% solution) in 2.5 cc
saline inhaled through nebulizer
e. intravenous volume resuscitation
5. Administer secondary therapy as indicated:
a. corticosteroids
b. antihistamines
c. pressors
d. glucagon infusion
C. Education of patient and family
1. Use of epinephrine auto-injectors
2. Medic alert bracelets
3. Densensitization, if available
4. Outlined treatment plan for family/caregivers
about anaphylaxis in general, as well as specific agents
responsible for these reactions (e.g. food allergens,
insect venom, drugs and latex). These educational
materials should be provided to the patient and should
supplement the outlined treatment and prevention
plan. Medic alert bracelets can be helpful in some cases.
A few key observation guidelines regarding pa-
tients experiencing anaphylactic reactions need to be
discussed. Patients experiencing mild to moderate
episodes of anaphylaxis who do not have severe res-
piratory and cardiovascular symptoms should be ob-
served for at least 4 hours in a clinic setting before
discharge. For example, a patient receiving immuno-
therapy injections who experiences anaphylaxis should
be observed in a clinic setting because late phase reac-
tions, especially involving the lung, may occur. Pa-
tients experiencing serious anaphylaxis should be hos-
pitalized and monitored for at least 24 hours. In addi-
tion to the possibility of late phase allergic reaction,
these anaphylactic reactions can become protracted and
very difficult to manage in an outpatient setting. These
patients need very close medical observation and may
require intensive medical treatment and monitoring.
There are certain situations in which allergy de-
sensitization protocols can be offered to the patient.’”
The best examples include anaphylaxis to penicillin,
insect venom anaphylaxis, and in some cases, aspirin.
These procedures are performed under
the supervision of an allergist and are
typically undertaken in a medical facility
equipped to manage acute anaphylactic
episodes. Once the patient is desensi-
tized, a maintenance protocol is followed
to prevent future episodes of anaphylaxis
if the patient accidentally is exposed to
the offending allergen.
In summary, the apparent rise in the
incidence of anaphylaxis appears to be a
direct result of an increasing exposure to
allergens. The mast cell is the central cell
in the initiation of these generalized re-
actions. A detailed history and clinical
assessment can be very useful in the dif-
ferential diagnosis of these generalized
reactions. Most cases of anaphylaxis are
secondary to insect stings, antibiotics,
common food allergens, and immuno-
therapy injections. A delay in their rec-
ognition can result in significant morbid-
ity and mortality. The prompt adminis-
tration of epinephrine remains the main-
stay of therapy for acute anaphylactic
episodes and educating the patient and
family is critical in the overall treatment
and prevention of future episodes of ana-
phylaxis. Finally, keep in mind that pa-
tients with asthma may be at higher risk
for more severe anaphylactic reactions.
References
1. Bochner BS, Lichtenstein LM. Anaphylaxis. N Engl J Med
1991;324:1785-90.
2. Sorensen HT, Nielsen B, Ostergaard Nielsen J. Anaphy-
lactic shock occurring outside hospitals Allergy 1989 j44: 288-90.
3. Winbery SL, Lieberman PL. Anaphylaxis. Immunol Clin
N Am 1995;15: 447-75.
4. Schwartz LB, Metcalfe DD, Miller JS, Earl H, Sullivan T.
Tryptase levels as an indicator of mast-cell activation in sys-
temic anaphylaxis and mastocytocis. N Engl J Med
1987;316:1622-6.
5. Systemic Reactions. In: Virant ES, editor. Immunology
and Allergy Clinics of North America Philadelphia: WB
Saunders, 1995;15:1-640.
6. Yunginger JW, Nelson DR, Squillance DL, et al. Labora-
tory investigation of deaths due to anaphylaxis. J Forensic
Sci 1991;36:857-65.
7. Lockey RE. Adverse reactions associated with skin testing
and immunotherapy. Allergy Proc 1995;16:293-6.
8. Slater JE. Allergic reactions to natural rubber. Ann Al-
lergy 1992;68:203-9.
9. Position Statement. Guidelines to minimize the risk from
systemic reactions caused by immunotherapy with allergenic
extracts. J Allergy Clin Immunol 1994;93: 811-2.
10. Reisman RE. Insect stings. N Engl J Med 1994;331:523-7.
Volume 93, Number 6 - November 1996
287
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Loss Prevention
There Ain't No Justice
J. Kelley Avery, M.DA
Case Report
A 16-month-old male infant who has had the usual
upper respiratory infections of babies - otitis, media,
red throat, bronchitis - and who has responded to treat-
ment with antibiotics, is brought to his doctor on the
10"^ of the month for sudden onset of fever, rhinor-
rhea, anorexia, and malaise. Examination reveals a red
throat, no significant adenopathy, a negative chest
examination, and a fever of 103. 2"F. An injection of
benzathine penicillin was given and acetaminophen
was prescribed for the fever.
Three days later the child had not improved, and
office notes describe a "very irritable" little boy who
still had a red throat and was still somewhat lethargic
and febrile. There were no other positive physical find-
ings. At this point, the attending physician added to
the treatment cephalexin, a cephalosporin, by mouth.
The following day the mother brought the child to
the emergency room with continued fever, anorexia,
and irritability; the fever again was recorded as 103.2“F
and again the examination showed only a "red throat."
A specific reference in the record stated that there was
"no stiff neck." The mother was advised to continue
the cephalexin and ASA for fever. Faboratory studies
revealed a WBC count of 13,400/cu mm with 45% seg-
mented neutrophils, 3% bands, and 52% lymphocytes.
Two days later, six days after the onset of fever,
with the child still very sick, the examination showed
a stiff neck. CSF studies showed 267 WBCs, mostly
segmented neutrophils, and an elevated protein; cul-
tures grew Hemophilus influenzae, type B. Amoxicillin
was begun immediately after the spinal fluid was ob-
tained. The child was afebrile in four days and recov-
ered within a week. The amoxicillin was continued for
a total of 10 days.
As the patient improved, it became apparent that
his hearing was severely impaired. After a thorough
evaluation by a speech and hearing center, it was de-
* Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Company, Brentwood, TN.
This article appeared in the Journal of the Tennessee Medical
Association in August 1990. It is reprinted here with permission.
termined that the deafness, in all probability due to
the Hemophilus, was very probably going to be per-
manent. Shortly afterward, a lawsuit was filed charg-
ing the attending physician with negligence because
of the delay in diagnosis of the true nature of the child's
illness. It was charged that this delay in diagnosis
caused the little boy's deafness.
Loss Prevention Comments
In the development of this case, expert witnesses
gave testimony on both sides of this issue. Very cred-
ible physicians took opposite views on the relation-
ship of the delay in diagnosis to the complication of
deafness. The expert for the plaintiff stated that the
probability was that if the antibiotic had been started
earlier, the deafness would not have occurred. The
defense expert pointed out that at least half the time
deafness would have developed in a situation like this
regardless of when appropriate treatment had been
started.
The defense further pointed out that on the first
day that any evidence of meningeal irritation (stiff neck)
developed appropriate treatment was begun.
The claims review committee of SVMIC thoroughly
reviewed this case on two occasions and considered
that there had been no significant deviation from an
acceptable standard of care.
Both the attending physician and the emergency
room physician were sued and the jury found against
both. The award was in the high six figures.
While there was no deviation from the standard
of care in this case, can we learn anything from this
case that might prevent this type of litigation? Yes. We
can learn that a jury faced with a situation of this type
is likely to award lots of money because of the ex-
penses incurred and the likelihood of future costs re-
lated to the child's deafness. We can also learn to ex-
amine the CSF early in the patient with a febrile ill-
ness where there is no apparent cause and there has
been no response to the usual treatment. For the phy-
sician caught up in this kind of situation there truly
"ain't no justice."
Volume 93, Number 6 - November 1996
289
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Cardiology Commentary and Update
Jack McKee, M.D.*
Julian Javier, M.D.**
Vito Calandro, M.D.**
Eugene Smith, M.D.**
Kwabena Mawulawde, M.D.***
J. David Talley, M.D.**
Advances in the Treatment of Left Ventricular Systolic Dysfunction
The treatment of congestive heart failure (CHF)
was performed centuries before the physiologic basis
of the disease was accepted. Certainly the Romans,
and quite possibly the ancient Egyptians, used plants
medicinally which contained cardiac glycosides. Al-
though these therapies were effective in relieving symp-
toms, they were not directed intentionally at a specific
physiologic defect. Hence, it was not until systolic
dysfunction was conceptually understood that thera-
pies could be designed to correct the various aspects
of CHF. This article describes some of these modalities
in terms of mechanisms of action, and indications for
use in clinical practice.
Patient Presentation
The patient is a 59-year-old white male with a his-
tory of diabetes mellitus. He sustained an acute infe-
rior myocardial infarction and was transferred to our
hospital 21-days later for cardiac catheterization (see
Complete Cardiac Diagnosis, Table 1). He had severe
triple vessel disease: left main 50-60% distal stenosis,
left anterior descending 40-50% stenosis, circumflex
30% stenosis, and right coronary 70-80% stenosis. His
left ventricular ejection fraction was < 25%, confirmed
by MUGA. While being evaluated for surgical
revascularization, he developed florid pulmonary
edema and cardiogenic shock, requiring intubation and
intraaortic balloon pump (lABP) support. He was even-
tually weaned from mechanical support, but required
a continuous infusion of vasopressors to maintain an
adequate cardiac output. There was no evidence of
viable myocardium when studied with a perfusion
scan. There was no contraindication for cardiac trans-
* Jack McKee, M.D., is with the Department of Internal Medi-
cine, UAMS Medical Center.
** Julian Javier, M.D., Vito Calandro, M.D., Eugene Smith, M.D.,
and J. David Talley, M.D., are with the Division of Cardiology,
Department of Internal Medicine, UAMS Medical Center.
*** Kwabena Mawulawde, M.D., is with the Division of Cardio-
thoracic Surgery, Department of Surgery, UAMS Medical Center.
plant and he was listed as status I. Subsequently, mini-
mal exertion such as sitting up in bed produced he-
modynamic instability and oxygen desaturation. He
was considered as candidate for left ventricular assist
device (LVAD), and underwent surgery on 9/12/96 for
placement of a Heartmate model lOOOA® Thermo
Cardiosystems Inc., Woburn, MA) assist device (Fig-
ure 1). He has had a slow and steady recovery.
Two weeks after LVAD placement, he was exercis-
ing using a stationary bicycle four times per day for 15
minutes, and can now ambulate and exercise with
minimal assistance. His creatinine has improved from
2.4 mg/dl prior to surgery to 0.9 mg/dl, indicating a
significant improvement in end organ perfusion. He
is currently awaiting cardiac transplantation.
Etiologies of Congestive Heart Failure
There are many causes of CHF, but in the United
States several categories dominate in terms of incidence
within the population. In general, diseases which cause
functional changes within the myocardium have the
potential for altering contractility. It is when cardiac
function becomes inadequate to provide necessary
perfusion to end organs that CHF manifests clinically.
In an attempt to improve this problem, the body re-
acts by activating neuroendocrine systems.’ From a
functional standpoint, this a sound mechanism pro-
vided that there is sufficient cardiac reserve. However,
in states where impaired contractility is severe, no such
reserve exists and the neuroendocrine system actually
worsens hemodynamics and thus the symptoms of
heart failure.^
Diseases that produce cardiac injury directly may
be ischemic, infectious, toxic, or infiltrative. These may
present as acute illnesses with rapid deterioration, or
as insidious processes that become apparent only af-
ter exhaustive diagnostic testing. Examples include:
atherosclerotic heart disease, cardiomyopathy from
viruses such as group B coxsackievirus, alcoholic or
chemotherapy-related cardiomyopathy, and deposition
Volume 93, Number 6 - November 1996
291
Table 1
Complete Cardiac Diagnosis
Etiology:
Atherosclerotic heart disease
Anatomy:
Cardiac catheterization (8/1/96); left main 50-60% distal stenosis, 50%
mid stenosis of left anterior descending coronary artery with 80% steno-
sis of the first diagonal branch, 30% mid stenosis of the circumflex
coronary artery with 80% stenosis of the first obtuse marginal, 70-80%
mid stenosis of the right coronary artery.
Physiology:
Cardiac catheterization; < 25% left ventricular ejection fraction
Echocardiogram; global hypokinesis with anterior apical dyskinesis.
MUG A; left ventricular ejection fraction 23%
Functional:
Class IV
Objective:
Severe disease
of light chains in amyloidosis.
Another important basis for the development of
cardiac failure is the eventual decompensation of ven-
tricular architecture and function from hypertrophic
states. This would encompass those diseases which
require increased myocardial mass to sustain an ad-
equate cardiac output. Examples in this category would
include among others, systemic arterial hypertension,
and valvular heart disease.
The list of diseases and pathological states which
can give rise to CHF is long, and the treatment should
be targeted to the specific etiology. When this is not
possible, treatment should be directed to treat clinical
symptoms in order to improve patients quality of life
and long term survival. Ultimately, the underlying
physiology in systolic dysfunction is identical and thus
requires treatment in a similar manner-albeit to vary-
ing degrees. This should not imply that mortality or
morbidity are independent of etiology, as will be illus-
trated in the section on treatment.
Pharmacological Management
The goal in managing any disease with medica-
tion is to cure the underlying disease or to relieve symp-
toms with minimal or acceptable side effects. The treat-
ment of CHF has been practiced for centuries with
local preparations and plant extracts. Over time, these
remedies were replaced or modified based on scien-
tific discovery and an understanding of the pathologic
processes leading to CHF. Currently, it is standard prac-
tice for the clinician to use vasodilators, inotropic
agents, and diuretics, either alone or in combination,
for the treatment of CHF. Additionally, there are sev-
eral clinical trials underway which hopefully will show
that other classes of drugs are effective in modifying
the morbidity and mortality of ventricular failure.
Cardiac Glycosides. Digoxin and related compounds
are among the oldest medications which are still in
use today. Although digoxin
has been used for many
years, it was not until recently
that randomized trials were
done looking at its effects in
patients with heart failure.
The Randomized Assessment
of Digoxin in Inhibitors of the
Angiotensin Converting En-
zyme (RADIANCE) trial
showed that when digoxin
was withdrawn from patients
taking a combination of
digoxin, an angiotensin con-
verting enzyme (ACE) inhibi-
tor, and a diuretic, they ex-
perienced a significant de-
crease in exercise tolerance.
New York Heart Association
(NYHA) class, and quality of life. '* Despite these find-
ings however, there is a paucity of clinical trials ad-
dressing its effect on mortality when used in conges-
tive failure. Recently, the Digitalis Investigators Group
(DIG) presented data from a randomized trial in which
patients with congestive failure were given digoxin or
placebo. The study found no improvement in patients
treated with digoxin, although a significant reduction
in hospitalizations for worsening CHF was noted.^
Digoxin not only acts by providing inotropic sup-
port to the failing heart, studies have shown that it
also plays a role in the autonomic and neurohumoral
systems in patients with CHF, which is fundamental
to the pathogenesis of CHF’
ACE Inhibitors. ACE Inhibitors prevent the conver-
sion of angiotensin I to angiotensin II, and thereby
interfere with the production of aldosterone. In a sense,
this is the antithesis of the neurohumoral effects en-
countered in progressive CHF.^It should come as no
surprise then, that ACE inhibitors have shown to be
of dramatic benefit in the management of CHF. The
Cooperative North Scandinavian Enalapril Survival
Study (CONSENSUS), which studied patients with
severe CHF showed a 31% decrease in 1-year mortal-
ity in patients taking enalapril. In the Studies of Feft
Ventricular Dysfunction (SOFVD) trial, which evalu-
ated patients with moderate to severe CHF, there was
a survival benefit at one, two and maintained at up to
four years in those taking an ACE inhibitor.^
The addition of an ACE inhibitor aids in the con-
trol of symptomatic CHF, decreases the need for hos-
pitalization, and thus far is the only medication that
has shown to prolong survival in patients with left
ventricular dysfunction. ACE inhibitors have become
the mainstay therapy for CHF.
Calcium Channel Blockers. These medications have
not been used extensively for the treatment of CHF.
Despite calcium channel blockers being potent vasodi-
lator drugs, patients with left ventricular dysfunction
292
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
have shown to have an unfavorable
response to treatment with calcium
antagonists such as nifedipine. How-
ever, newer classes of dihy-
dropyridines were studied in the Pro-
spective Randomized Amlodipine
Survival Evaluation (PRAISE). In this
trial, there was a significant reduction
in death or repeat hospitalization for
a major cardiac event in those patients
with nonischemic cardiomyopathy,
but not in those with ischemic cardi-
omyopathy.^
There are currently ongoing tri-
als evaluating the role of newer calcium
antagonists in the treatment of CHE.
Beta-Adrenergic Antagonists.
Beta-blockers have historically been
considered contraindicated in patients
with left ventricular dysfunction.
However, with the understanding of
the pathophysiology of heart failure,
specifically the importance of the au-
tonomic nervous system, investiga-
tors have become more interested in
their use in patients with CHE.
Metoprolol has been shown to im-
prove exercise tolerance and quality
of life in patients with dilated cardi-
omyopathy.’” Carvedilol, a drug with
a and P effects, has also shown great
promise in treatment of CHE.”
Diuretics. Diuretics have been a
mainstay in the symptomatic control
of CHE for many years. They act pri-
marily by reducing preload and con-
sequently the filling pressure of the
failing myocardium. They do little to
improve cardiac output, and have not been shown to
alter mortality in patients with CHE. Therefore, diuret-
ics are used mainly for symptomatic control of chronic
CHE, or in settings such as acute pulmonary edema.
Mechanical Devices
CHE can be thought of as a disease process with a
spectrum of symptoms ranging from asymptotic to
positively incapacitating despite maximal use of medi-
cations. It is for the latter group that interventional
devices have been designed in order to sustain life,
usually in attempt to provide cardiac transplantation
in the near term. In general they are intended to re-
lieve the myocardium of its workload. By doing so, it
is possible to allow the heart to "rest," or in some
cases to be "assisted" for prolonged periods.
Intraaortic Balloon Pump. The lABP was designed
to be inserted into the aorta with inflation and defla-
tion synchronized with diastole and systole respec-
tively. Importantly, with this device in place, there is
immediate afterload reduction which produces a de-
crease in workload for the failing myocardium. Most
of the data regarding the indications for use of such a
device are in the settings of acute myocardial infarc-
tion, and in prophylaxis for high-risk coronary
angioplasty. In these situations, increases in coronary
artery blood flow velocity is thought to be an impor-
tant mechanism of action.’^ Indeed, the use of an lABP
in patients with cardiogenic shock or refractory CHE
would be considered one alternative to an otherwise
baleful outcome. However, there are reports of pa-
tients successfully remaining on lABP for several
months while awaiting transplant.’’
Left Ventricular Assist Device. One of the most in-
novative devices currently in use is the left ventricular
assist device (LVAD). The development of the LVAD
was born from earlier attempts to design a more per-
manent artificial heart which met with limited suc-
cess. The basic principle of the LVAD is to mechani-
Volume 93, Number 6 - November 1996
293
cally "assist" the left ventricle with a pump which is
outside of the ventricular chamber. Blood is taken
through an orifice in the ventricular apex, and received
into a pump which in turn drives the blood into the
aorta by way of a conduit. The entire unit is posi-
tioned within the abdomen while the conduits pass
through the diaphragm, one from apex to the pump
and another connecting the pump to the aorta. The
LVAD is then connected to an external energy supply
which may either be worn or carried depending upon
the particular model.
There are two types of LVAD, pulsatile and
nonpulsatile. Nonpulsatile devices are rarely used to-
day as a bridge to transplantation since they require
that the patient remain in bed, often intubated, and
anticoagulated making them more susceptible to com-
plications.
Pulsatile devices, like the one used in our patient,
allows for patient mobility and can provide support
for extended period of time periods while awaiting
transplantation. LVAD's allow the patient to ambulate
and even exercise prior to their transplant. The im-
provement in cardiac output is also reflected by im-
proved function of other organs such as kidneys, lungs,
and even the neurohumoral system.
Although the initial use of left ventricular assist
devices was associated with 40-50% mortality, nowa-
days survival until transplantation is close to 90%. This
has been attributed to the use of more sophisticated
devices and better patient selection. In one series of 21
patients, 81% were successfully supported until trans-
plantation with all of these patients achieving NYHA
class I or II prior to transplantation.’’’ While success
has been great, it is important to mention that these
devices are not without risks. Possible complications
include: infection, peripheral emboli, and development
of antibodies secondary to the use of multiple transfu-
sions of red blood cells and platelets.
Transplantation
Ironically, the last step in the treatment of CHF
offers the greatest improvement in symptoms and prog-
nosis. This holds true only for those patients with se-
vere congestive failure, since the relative morbidity and
mortality of their disease outweighs the risks inherent
in transplantation.
Undoubtedly, patients with New York Heart As-
sociation class IV CHF who undergo transplantation
have an improvement in survival when compared with
those managed medically.’-^ With the aid of new and
more specific immunosuppressive therapies which
decrease the incidence of organ rejection and makes
the patient less susceptible to opportunistic infection,
the current 1 and 5 year survival of cardiac transplant
patients is 80-90% and 60-70%, respectively.’’’
Conclusion
CHF is a complex pathologic process which pro-
vides the clinician with many diagnostic and thera-
294
peutic challenges. Once the pathophysiology of sys-
tolic dysfunction was understood, therapies could be
designed in an attempt to alter the clinical course. Pres-
ently, medications such as ACE inhibitors have been
shown to improve survival while aiding in symptom-
atic control. With the addition of newer medications it
may ultimately be possible to stem the progression of
even the most severe congestive failure. Until then;
however, there are invasive measures to provide sup-
port as a bridge to transplant. It remains to be seen
which will provide the greater contribution.
References
1. Levine TB, Francis GS, et al. Activity of the sympathetic
nervous system and renin-angiotensin system assessed by
plasma hormone levels and their relation to hemodynamic
abnormalities in congestive heart failure. Am J Cardiol
1982;49:1659-66.
2. Packer M. The neurohumoral hypothesis: a theory to ex-
plain the mechanism of disease progression in heart failure.
J Am Coll Cardiol 1 992;20:248-54.
3. Weber KT. Cardiac interstitium in health and disease: The
fibrillar collagen network. J Am Coll Cardiol 1989;13:1637-52.
4. Packer M, Gheorghiade M, Young JB, et al. For the RADI-
ANCE Study. Withdrawal of digoxin from patients with
chronic heart failure treated with angiotensin converting
enzyme inhibitors. N Engl J Med 1993;329:17.
5. As presented by; Garg R, Gorlin R. The effect of digitalis
on mortality and hospitalizations in patients with heart fail-
ure. American College of Cardiology, 45th Annual Scientific
Session. Orlando, Florida. USA, March 24-27, 1996.
6. The CONSENSUS Trial Study Group. Effect of enalapril
on mortality in severe congestive heart failure: results of the
Cooperative North Scandinavian Enalapril Survival Study
(CONSENSUS). N Engl J Med 1987;31 6:1 429-35.
7. SOLVD Investigators. Effect of enalapril on survival in
patients with reduced left-ventricular ejection fractions and
congestive heart failure. N Engl J Med 1991;325:293-302.
8. Elkayam U, Shotan A, Mehra A, Ostrzega E. Calcium
channel blockers in heart failure. J Am Coll Cardiol
1993;22:139A-144A.
9. Packer M, O'Connor CM, Ghali JK, et al. Effect of
amlodipine on morbidity and mortality in severe chronic heart
failure. N Engl J Med 1996;335:1 107- 1 4.
10. Waagstein F, Bristow MR, Swedberg K, et al. Beneficial
effects of metoprolol in idiopathic dilated cardiomyopathy.
Lancet 1993;342:1441-6.
11. Packer M, Bristow MR, Cohn JN, et al. The effect of
carvedilol on morbidity and mortality in patients with chronic
heart failure. N Engl J Med 1996:334; 1349-55.
12. Ohman EM, George BS, White CJ, et al. Use of aortic
counterpulsation to improve sustained coronary artery pa-
tency during acute myocardial infarction. Circulation
1994;90:792-3.
13. Torre-Amione G, Kapadia S, et al. Evolving concepts
regarding selection of patients for cardiac transplantation.
Chest 1996; 109:223-32.
14. Oz MC, Rose EA, Levin FIR. Selection criteria for place-
ment of left ventricular assist devices. Am Heart J
1995;129:173-7.
15. McCarthy PM. Heartmate implantable left ventricular
assist device: bridge to transplantation and future applica-
tions. Ann of Thorac Surg 1995; 59(2 suppl) ;s46-51.
16. Sadowsky HS. Cardiac transplantation; a review. Phys
Ther 1996;76:498-515.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Information provided by the Arkansas Department of Health, Division of Epidemiology
Eastern Equine Encephalitis Virus Isolated in South Arkansas
Eastern Equine Encephalitis (EEE) in horses oc-
curs sporadically in Arkansas and surrounding states
(Louisiana, Georgia, Elorida, Texas, etc.). EEE is main-
tained in a natural cycle between the mosquito Culiseta
melanura and wild birds. Other species of mosqui-
toes may transmit the virus from infected birds to
horses, emus and man.
Reports of EEE in emus appear to be increasing as
their popularity increases. These birds are exquis-
itely susceptible to infection with the EEE virus and
serve as an excellent indicator that mosquitoes in the
area are carriers of the virus. EEE virus has recently
been isolated from a flock of emus in El Dorado. Thirty
of 177 birds have shown bloody diarrhea and died.
The virus has been identified as the causative agent
by a laboratory at Texas A&M University. EEE virus
was also isolated several days later from a flock of 50
emus about 50 miles away where six showed bloody
diarrhea and died. Those isolates are further evidence
that the virus is present in mosquitoes in southern
Arkansas and possibly the entire state. It is possible,
but not proven, that humans may become infected
with the disease by exposure to infected blood and
tissues of EEE infected emus.
The disease is transmissible to humans by the bite
of an infected mosquito. Headaches, drowsiness, fe-
ver, vomiting and stiff neck are the usual presenting
symptoms. Tremors, mental confusion, convulsions
and coma may develop rapidly. Treatment is sup-
portive as in other viral encephalitides. Serum from
suspected patients may be sent to the virology lab at
the Arkansas Department of Health (ADH) for further
submission to the CDC laboratory in Fort Collins, CO.
A complete screen for most arboviral diseases will be
conducted. Please submit at least 2 ml of serum.
EEE has occurred in recent years in horses from
southern Pulaski county to south central Arkansas.
Clinical signs of encephalomyelitis occur about 5 days
after infection and most deaths in horses occur 2 or 3
days later. Veterinarians are requested to submit the
intact brain to the ADH lab for rabies testing. Brain
tissue will be sent to the U.S. Department of Agricul-
ture laboratory in Ames, Iowa for identification of the
EEE virus. It is recommended that all equines in the
area be vaccinated annually against EEE.
To prevent human cases, individual protective
measures should be taken to avoid mosquito infested
areas. The use of insect repellents containing DEET
on exterior clothing and wearing protective clothing is
recommended.
For more information, call the Arkansas Depart-
ment of Health, Division of Epidemiology, at (501)661-2597.
Volume 93, Number 6 - November 1996
295
Reported Cases of Selected Diseases in Arkansas
ProfQe for August 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
Aup. 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1994
Campylobacteriosis
33
163
103
153
124
187
Giardiasis
16
99
81
131
65
126
Shigellosis
29
83
86
176
128
193
Salmonellosis
65
283
200
332
206
534
Hepatitis A
34
337
397
663
166
253
Hepatitis B
5
55
50
83
36
60
HIB
0
0
5
6
3
5
Meningococcal Infections
1
25
26
39
39
55
Viral Meningitis
8
24
29
31
53
62
Lyme Disease
0
20
9
11
14
15
Rocky Mountain Spotted Fever
2
12
26
31
16
18
Tularemia
2
15
19
22
20
23
Measles
0
0
2
2
1
5
Mumps
0
1
5
5
5
7
Gonorrhea
424
3391
3497
5437
4712
7078
Syphilis
50
574
719
1017
728
1096
Legionellosis
0
1
5
5
10
16
Pertussis
0
4
53
59
30
33
Tuberculosis
8
126
147
271
181
264
296
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Getting Acquainted
Gerald A. Stolz, Jr., M.D.
Newly Elected Chairman of the AMS Council
Dr. Gerald A. Stolz, Jr., President and Laboratory Director with Pa-
thology Services Laboratory in Russellville, was elected Chairman of the
AMS Council in May of this year. To him, being a part of the AMS means
giving as much as he possibly can to the organization, especially knowing
that this effort improves the health of all Arkansans.
With one Council meeting under his belt. Dr. Stolz will chair his sec-
ond meeting this month (November 16-17 at Lake Hamilton Resort in Hot
Springs). As Chairman of the Council, his duties include residing at all
meetings of the Council, serving as Chairman of the Executive Committee
of the Council and appointing the Council committees.
When asked what he believes is the most important issue facing the
AMS, Dr. Stolz said, "With all of the managed care impact, at least pre-
serving and hopefully increasing physician interest, not only just being a
member, but being an active participant as well."
Dr. Stolz has a long history of service to the medical field. In addition
to his membership and involvement with the AMS, he is a member of
Alpha Omega Alpha; Fellow, American Society of Clinical Pathologists;
Arkansas Society of Pathologists; American Medical Association; Ameri-
can Pathology Foundation; Pope County Medical Society and Fellow, Col-
lege of American Pathologists.
He served as President of the Arkansas Society of Pathologists in 1993/
1994 and is a past President of the Pope County Medical Society. From
1975 to 1979, he was secretary-treasurer of the Arkansas Society of Pa-
thologists. He has been a member of the Arkansas Foundation for Medical
Care since 1977 and has served in various other positions for hospitals
and societies.
His professional affiliations are numerous. Since 1973, he has been
Director of Pathology and Laboratory Services with AMI-St.. Mary's Re-
gional Medical Center in Russellville. With Dardanelle Hospital, he began
as a consulting pathologist in 1973 and in 1992 became the Director of
Pathology and Laboratory Services. In addition. Dr. Stolz is affiliated with
a laboratory in Fort Smith and hospitals in Danville, Clarksville, Booneville,
Ozark, Mena, Waldron, Paris and Heber Springs.
Dr. Stolz's attended the University of Arkansas School of Medicine in
1965 after he graduated from Hendrix College in Conway. He began his
residency training in anatomical and clinical pathology at UAMS's Uni-
versity Hospital in 1969. He then went on to train at USPHS Hospital and
Charity Hospital (LSU) in New Orleans and returned to University Hos-
pital in Little Rock where he completed his training in 1973.
Dr. Stolz is certified in Anatomic and Clinical Pathology with the
American Board of Pathology and the American Board of Quality Assur-
ance and Utilization Review.
Preserving and increasing
physician interest is the
most important issue
facing the AMS, said Dr.
Stolz-
Date & place of birth: October
29, 1944, in El Dorado
Spouse: Judy, college professor
Son: Greg, age 26, athletic trainer
Hobbies: Boating on Greers Ferry
Lake, traveling to interesting
areas and deep sea fishing
If I had a different job. I'd be:
Head coach of a college football
team playing for a national
championship
The person I most admire: Vince
Lombardi (former coach of Green
Bay Packers football team)
Best Habit: Loyalty and keeping
promises
Worst Habit: Never being on time
The turning point of my life was
when: 1 attended Hendrix College
When I was a child, I wanted to
grow up to be: A doctor
My work philosophy: I give
120% to work and expect 110%
from employees
One word to sum me up is:
Complex
Volume 93, Number 6 - November 1996
297
iMii Outdoor MD
Information provided by
the Arkansas Game & Fish Commission
/
'y/'
'N ^ ^ » /
Duck hunting to be open every weekend
this season
Duck hunting in Arkansas this season will be open every weekend
from before Thanksgiving until deep into January.
The duck and goose hunting dates and bag limits were set by
the Arkansas Game and Fish Commission at its August monthly
meeting.
The duck hunting dates are: Nov. 23-Dec. 8, Dec. 14-22 and
Dec. 26-Jan. 19. The structure of 50 days of hunting and a maximum of five ducks
per day is the same as last season. The only change in the bag limit is that hunters
may kill two redhead ducks a day - last year, just one redhead was allowed. Four
mallards can be taken per day, but only one can be a female.
Goose hunting dates continued to be liberalized by the Commission in accordance with guidelines
handed down by the U.S. Fish and Wildlife Service. Snow geese have multiplied rapidly over the North
American continent and many more are wintering in Arkansas than in past years.
Snow goose hunting season in Arkansas this year will be 107 days, and 10 snow geese per day can
be taken in addition to the limits on Canada geese and white-fronted (specklebelly) geese.
The goose hunting dates are: Snow geese, Nov. 23-March 9; bag limit 10 a day; possession limit 30,
up from last year's 20. Canada geese. East Arkansas Zone, Jan. 18-Feb. 9; bag limit two a day. Canada
geese. West Arkansas Zone, Jan. 25-Feb. 2 and Feb. 5-9; bag limit one a day. White-fronted geese: Nov.
23-Jan. 31; bag limit two a day.
Tim Moser, waterfowl biologist with the Commission, said, "All indications are for another really
good year in numbers of ducks. Last year, for the first time, Arkansas hunters killed over one million
ducks. Arkansas was first in the nation in the number of mallards taken by hunters, third in the nation
in total number of ducks taken and third in the nation in the number of ducks taken per hunter."
The statistics are compiled by the Fish and Wildlife Service from surveys of hunters. Current estima-
tions of North American duck populations are 89 million, Moser said.
Other duck hunting actions taken by the Commission at its August meeting:
1. If approved by the Fish and Wildlife Service, a youth-only day of duck hunting will be Dec. 23.
2. Waterfowl hunting will be mornings only, ending at noon, on Cane Creek Lake in Lincoln County in
southeast Arkansas.
3. The Shiloh Bay area on Lake Dardanelle, north of Interstate 40 at the northern edge of Russellville,
will be opened to Canada goose hunting.
Regulations tabloid gives details of hunting, fishing laws
Do you need to know the exact rules governing Arkansas hunting and fishing? These are available
in a tabloid newspaper from the Game and Fish Commission.
Jane Rice, publication editor for the Commission, said, "We have two publications on our regula-
tions. One is the compact summary booklets, one for hunting and another for fishing, that are available
from license dealers and Game and Fish offices all over the state. These will answer nearly all questions
about our rules. For the exact wording and legal terminology of the rules, some sportsmen may want
the official code regulations, which we update and print twice a year."
The regulations tabloids are free and can be obtained from the Game and Fish Commission's infor-
mation office at 223-6351.
298
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
New Members
EL DORADO
Daniels, Charles Dwayne, Orthopedic Surgery.
Medical Education, UAMS, 1991. Internship/Residency,
UAMS, 1992/1996.
FAYETTEVILLE
Davis, Thomas Jay, Anesthesiology. Medical Edu-
cation, UAMS, 1992. Internship/Residency, 1993/1996.
FLIPFIN
Itzig, Charles Blum, Jr., General Surgery. Medi-
cal Education, University of Mississippi, Jackson, 1965.
Internship, Baptist Memorial Hospital, Memphis, Ten-
nessee, 1966. Residency, VA Hospital, Memphis, Ten-
nessee, 1970. Board certified.
FORREST CITY
Sarinoglu, Cem, Obstetrics/Gynecology. Medical
Education, Ege University Medical School, Bornova,
Izmir, Turkey, 1986. Internship/Residency, University
of Tennessee, Memphis, 1993/1996.
FORT SMITH
Hughes, Juan M., Internal Medicine. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
1996.
Kelly, James Edward, III, Plastic Surgery. Medi-
cal Education, Queens University, Kingston, Ontario,
Canada, 1989. Internship/Residency, McMaster Uni-
versity, 1990/1994. Board eligible.
HOT SPRINGS
McGraham, Bethany A., Emergency Medicine.
Medical Education, Loyola University Stritch School
of Medicine, Maywood, Illinois, 1991. Internship,
Lutheran General, Park Ridge, Illinois, 1992. Residency,
Truman Medical Center, Kansas City, Missouri, 1995.
Board certified.
Spiers, Jon Phillip, Cardiovascular & Thoracic
Surgery. Medical Education, University of Tennessee,
Memphis, 1988. Internship, University of Tennessee,
Memphis, 1989. Residency, University of Tennessee,
Memphis, 1994, and Baylor College of Medicine, Hous-
ton, Texas, 1996. Board certified.
St. John, Melody Dawn, Rheumatology. Medical
Education, UAMS, 1990. Internship/Residency, UAMS,
1991/1992. Board certified.
Volume 93, Number 6 - November 1996
JACKSONVILLE
Pastor, Randy Joseph, Family Practice. Medical
Education, Ohio University College of Osteopathic
Medicine, Athens, 1986. Internship, Cuyahoga Falls
General Hospital, Ohio, 1987. Board certified.
LITTLE ROCK
Blackstock, Terri T., Gastroenterology. Medical
Education, UAMS, 1991. Internship/Residency, UAMS,
1992/1994. Board pending.
Brandt, John Oliver, Gastroenterology. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
1994/1996.
Field, Charles Robert, General Pediatrics. Medi-
cal Education, UAMS. Internship/Residency, UAMS,
1979/1981. Board certified.
Flamik, Darren E., Emergency Medicine. Medical
Education, Texas Tech University, Lubbock, 1993. In-
ternship/Residency, UAMS, 1996.
MOUNTAIN HOME
King, William Ronald, Anesthesiology. Medical
Education, University of Mississippi School of Medi-
cine, Jackson, 1992. Internship/Residency, University
of Texas Medical Branch, Galveston, 1996. Board eligible.
NEWPORT
Molnar, Istvan, Internal Medicine. Medical Edu-
cation, Semmelweis Medical School, Budapest, Hun-
gary, 1991. Internship/Residency, MeridiaMuron Hos-
pital, Cleveland, Ohio, 1993. Board certified.
RUSSELLVILLE
Pilkington, Neylon S., Pediatrics. Medical Edu-
cation, UAMS, 1993. Internship, UAMS, 1994. Resi-
dency, UAMS and Arkansas Children's Hospital, 1996.
SEARCY
Lowery, Ronald L., Ophthalmology. Medical Edu-
cation, UAMS, 1992. Internship, UAMS, 1993. Resi-
dency, University of South Florida, Tampa, 1996. Board
eligible.
SHERIDAN
Covington, Brenda Kaye, Family Medicine. Medi-
cal Education, UAMS, 1993. Internship/Residency,
UAMS, 1994/1996. Board eligible.
299
SPRINGDALE
Dunigan, Rodger Dale, Anesthesiology. Medical
Education, UAMS, 1992. Internship/Residency, UAMS,
1993/1996.
OUT OF STATE
Craytor, Bret Fredrick, Pulmonary Disease & Criti-
cal Care. Medical Education, University of Oklahoma
H. S. C., Oklahoma City, 1988. Internship/Residency,
University Hospital, Oklahoma City, 1989/1991. Fel-
lowship, University Hospital, Oklahoma City, 1996.
O'Sullivan, Patrick J., Neurology. Medical Edu-
cation, University College, Dublin, Ireland, 1964. In-
ternship, St. Vincent Hospital, Dublin, Ireland, 1965.
Residencies, St. Vincent Hospital, Dublin, Ireland,
1967, and University of Rochester, Strong Memorial
Hospital, New York, 1972. Board certified.
Pohle, Floyd G., Family Practice. Medical Educa-
tion, University Autonoma De Guadalajara,
Guadalajara, Jalisco, Mexico, 1987. Internship/Resi-
dency, AHEC-El Dorado.
RESIDENTS
Abu-Hamda, Emad Mohammad, Internal Medi-
cine. Medical Education, University of Jordan, Amman,
Jordan, 1994. Internship, UAMS.
Alderink, Carlisle Julianna, Pathology. Medical
Education, UAMS, 1993. Residency UAMS.
Behrens, Bing Xie, Neurology. Medical Education,
Sun Yat-sen University of Medical Sciences,
Guangzhou, PR. China, 1982. Internship/Residency,
UAMS.
Bhutta, Adnan T., Pediatrics. Medical Education,
Aga Khan University, Karacih, Pakistan, 1993. Resi-
dency, UAMS.
Esquibel, Ramona Dee, Emergency Medicine.
Medical Education, University of South Florida, Tampa,
1995. Internship/Residency, UAMS.
Fogata, Maria Luisa C., Radiology. Medical Edu-
cation, University of the Philippines, Manila, Philip-
pines, 1983. Internship, University of the Philippines,
Philippine General Hospital, Manila, 1989. Residency,
UAMS.
Griffin, David Dean, Internal Medicine. Medical
Education, UAMS, 1993. Internship/Residency, UAMS.
Hatley, Tina Whytsell, Pediatrics. Medical Edu-
cation, UAMS, 1996. Internship, UAMS.
Helsel, Jay Christopher, Anatomic and Clinical
Pathology. Medical Education, University of Missouri
School of Medicine, Kansas City, 1996. Residency,
UAMS.
Hendrix, Barry D., Family Practice. Medical Edu-
cation, UAMS, 1995. Internship, AHEC-Southwest.
Hernandez, Joseph M., Psychiatry. Medical Edu-
cation, University of Texas Medical School, San Anto-
300
nio, 1996. Internship/Residency, UAMS.
Hernandez, Nicole B., Emergency Medicine. Medi-
cal Education, University of Texas Medical School, San
Antonio, 1996. Internship/Residency, UAMS.
Hudson, Amy Rapp, Pathology. Medical Educa-
tion, University of Mississippi School of Medicine, Jack-
son, 1993. Residency, University of Mississippi/UAMS.
Kiser, Thomas Scott, Physical Medicine & Reha-
bilitation. Medical Education, University of Missouri,
Columbia, 1992. Internship, UAMS, 1993. Residency,
UAMS.
Kohli, Manish, Internal Medicine. Medical Edu-
cation, Maulana Azad Medical College, New Delhi,
India, 1990. Internship, Maulana Azad Medical Col-
lege, India. Residency, Cook County Hospital, Chi-
cago, Illinois, 1996. Fellowship, UAMS.
Mallory, Michael D., Pediatrics. Medical Educa-
tion, Medical College of Georgia, Augusta, 1994. In-
ternship/Residency, UAMS.
Netterville, J. Kevin, Emergency Medicine. Medi-
cal Education, Louisiana State University School of
Medicine, Shreveport, 1995. Internship/Residency,
UAMS.
Phillips, John David, Pediatrics. Medical Educa-
tion, University of Texas Southwestern Medical School,
Dallas, 1992. Internship, Children's Medical Center,
Dallas, 1993. Residency, UAMS.
Quintero, Mauricio, Family Medicine. Medical
Education, Pontificia Universidad Javeriana, Bogota,
Columbia, 1991. Internship, UAMS.
Sambasivan, Arathi, Anesthesiology. Medical
Education, Ambedkar Medical College, Bangalore, In-
dia, 1991. Internship/Residency, UAMS.
Singh, Malwinder, Internal Medicine/Pulmonary
& Critical Care. Medical Education, Government Medi-
cal College, Jammu, India, 1988. Internship/Residency,
Our Lady of Mercy Medical Center, Bronx, New York,
1994/1996. Fellowship, UAMS.
Stewart, Casey D., Pediatrics. Medical Education,
UAMS, 1996. Internship, UAMS.
Tran, Viet N., Orthopedic Surgery. Medical Edu-
cation, University of Texas Medical Branch, Galveston,
1996. Internship/Residency, UAMS.
Yeh, Y. Albert, Medicine/Pathology. Medical Edu-
cation, National Taiwan University, Taipei, Taiwan,
1989. Internship, National Taiwan University, 1989.
Residency, UAMS.
STUDENTS
Lee Eric Arthur
Holli Nicole Banks
Tanya R. Bell
Christian Gerrit Blankers
James Scott Bridges
Joe Christopher Colclasure
Constance J. Crisp
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Peter Marshall Daut
Scott Michael Dickson
Robert H. Ebert
LaDonna Dichelle Engelkes
Nova Darcel Goosby
Avis Alphonso Hall
Nada Harik
Edward Leslie Jackson
Robert Meacham Jarvis
Bryan Thomas Jennings
Larry Austin Johnson, Jr.
Daniel Baltz Kueter
Romona LeDay
Susanne Marie Lassieur
George Stephen Lawrence
Yolanda R. Lawson
Todd William Logsdon
Sonya Denise Marks
April Renee Marlin
Anthony Meads
Katherine Diane Newland
Adam Garrett Newman
Ajay S. Patel
Jody Warren Peebles
Corwin Durant Petty
Dean B. Priest, Jr.
Kimberly Anne Roberts
Christopher Patrick Schach
Daniel L. Schneider
Christopher Simpson
James H. Smith
Stacy Anne Smith-Foley
Melissa Diane Stennett
Benjaman Travis Wilkins
Robert B. Wilson, III
Jerry Mitchell Winkler
BE AN AIR FORCE
PHYSICIAN.
Become the dedicated physician you
want to be while serving your country in
today’s Air Force. Discover the tremen-
dous benefits of Air Force medicine. Talk
to an Air Force medical program manag-
er about the quality lifestyle and benefits
you enjoy as an Air Force professional,
along with:
• 30 days vacation with pay per year
• Dedicated, professional staff
• Non-contributing retirement plan if
qualified
Today’s Air Force offers the medical envi-
ronment you seek. Find out how to quali-
fy. Call health professions
TOLL FREE 1-800-423-USAF
Volume 93, Number 6 - November 1996
301
Your Spouse is the
of Our Organization
Membership in the Medical Society Alliance will provide your spouse with the following tools:
• Education and opportunities to impact legislative issues that affect your profession
• Participation in community health education and action projects that enhance the image of the medical
community
• Support for the future of medicine through assistance to doctors in training (AMA- ERF)
• A peer group that understands the challenges unique to physicians and their families
• A stronger, unified voice for the family of medicine
Call the AMSA at 501-224-8967 to ask whether your county has an organized alliance. If it doesn’t, your
spouse can become a Member-at large and will receive all the publications and information from state and
national, as well having an opportunity to participate in state-wide projects.
Show your support for your spouse by giving the gift of membership:
SEND DUES ($40 plus ) * TO:
AMS Alliance
P.O. Box 55088
Little Rock, AR 72215-5088
* County Dues Vary
Name ;
Address: ^County:
City: estate: Zip:
Phone: Legislative District:
Would you be willing to contact your Senator or Representative regarding health care issues? Yes No
Physician’s Name: DOB: Specialty:
Make checks payable to:
ARKANSAS MEDICAL
SOCIETY ALLIANCE
Radiological Case
of the Month
David Marshfield, M.D., Editor
Authors
Ramesh Avva, M.D.
David R. McFarland, M.D.
John F. Eidt, M.D.
History:
A 37-year-old right-handed man presented with a six-month history of pain and numbness in the index and long
fingers of the left hand. The patient works as a lumberjack and has a 40 pack-year history of smoking. There was no
history of diabetes mellitus, hypertension or heart disease. Physical examination revealed skin breakdown on the
distal aspectof the third digit with patches of necrosis and wet gangrene, and thinning and discoloration of the skin on
the distal aspect of the second digit.
Figure 1
Figure 2
Figures:
Figure 1: Digital arteriogram showing aneurysm of distal ulnar artery (arrow) and embolization of numerous digital
branch arteries (arrowheads).
Figure 2: Digital subtraction arteriogram showing pronounced lack of digital artery filling.
Volume 93, Number 6 - November 1996
303
Hypothenar Hammer Syndrome
Diagnostic Examination:
Diagnostic arteriography of the right upper extremity from a common femoral artery approach. The examination
(Figures 1 and 2) revealed an aneurysm of the ulnar artery at the wrist with embolization of digital branches to the
second and third phalanges. The remainder of the arteriogram was normal.
Diagnosis: Hypothenar Hammer Syndrome resulting from repetitive arterial trauma secondary to occupational activity.
Discussion:
The hypothenar eminence of the hand is often used to strike tools or objects forcefully in some occupations or is
subject to vibratory stresses for prolonged periods of time. These actions can cause repeated episodes where the
hook of the hamate bone strikes either the distal ulnar artery or the proximal portion of the superficial palmar arch.
The blunt arterial injury leads to vasospasm, vessel stenosis or occlusion, or aneurysm formation with distal embo-
lization. Symptoms of digital ischemia, unilateral Raynaud’s phenomenon or pulsatile mass may result. This constel-
lation of history and symptoms is called the Hypothenar Hammer Syndrome, or post-traumatic digital ischemia.
Numerous radiologic appearances of the hypothenar hammer syndrome exist. Kaji et al devised a classification
system which divided them into three types. Type I involves just stenosis of the superficial palmar arch. Type II
involves either occlusion of the superficial palmar arch at the hook of the hamate, or occlusion of both the superficial
and deep palmar arches at this level. Type III demonstrates occlusion of the ulnar artery at the wrist with or without
occlusion of the dorsal carpal branch of the ulnar artery.
The different type of radiologic presentations occur because the arterial anatomy of the hand is complex and
subject to many variations. The superficial palmar arch is the major terminal branch of the ulnar artery and is com-
plete in only 70% of cases. The deep palmar arch is the terminal branch of the radial artery and is complete 97% of
the time. The degree of completeness of the superficial palmar arch and the presence of adequate collaterals may
militate the severity of symptoms or even eliminate symptoms altogether. In one study, 127 mechanics were studied
and 79 disclosed a history of using the palm of their hand as a hammer. Eleven of these patients had angiographically
proven ulnar artery occlusion, but the men complained of mild, occasional symptoms and no objective evidence of
ischemia was found.
Most affected patients are males with a mean age of 40 years and a range of 30-56 years in one series. Affected
individuals are often employed in the mining, forestry and construction industries. Treatment options have included
surgery with resection of the ulnar artery aneurysms and end-to-end reanastamosis, thoracic sympathectomy, and
conservative treatment with vasodilators, bed rest, cessation of the harmful activity and cessation of smoking. Good
outcome was seen using either approach in one series.
References:
1. Conn J. Jr., Bergan JJ, Bell, JL. “Hypothenar hammer syndrome: Posttraumatic digital ischemia” Surgery 68.6 (1970): 1122-1128.
2. Kaji H, Honoma H, Usui M, Yasuno Y, Saito K. “Hypothenar Hammer Syndrome in Workers Occupationally Exposed to
Vibrating Tools." Journal of Hand Surgery (British and European Volume) 18B (1983): 761-766.
3. Benedict KT, Fr., Chang W. McCready FJ. “The Hypothenar Hammer Syndrome.” Radiology 1 1 1 .1 (1971): 57-60.
4. Little JM, Ferguson DA. “The incidence of the hypothenar hammer syndrome.” Archives of Surgery 105 (1972): 684-685.
5. Vayssairat M, Debure C, Cornier J-M, Bruneval P, Laurian C, Juillet Y. “Hypothenar hammer syndrome: Seventeen cases with
long-term follow-up.” Journal of Vascular Surgery 5 (1987): 838-843.
Authors:
Ramesh Avva, M.D., is a resident in Diagnostic Radiology at UAMS.
David R. McFarland, M.D., is Associate Professor of Radiology at UAMS.
John F. Eidt, M.D., is Associate Professor of Surgery at UAMS
Editor:
David Marshfield, M.D., is Director of Radiology at Riverside Imaging Center and Clinical Associate Professor of Radiology at
UAMS.
304
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
THE ARMY RESERVE OFFERS UNIQUE AND
REWARDING EXPERIENCES.
As a medical officer in the Army Reserve you will be offered a
variety of challenges and rewards. You will also have a unique
array of advantages that will add a new dimension to your
civilian career, such as;
• special training programs
• advanced casualty care
• advanced trauma life support
• flight medicine
• continuing medical education programs and conferences
• physician networking
• attractive retirement benefits
• change of pace
It could be to your advantage to find out how well the Army
Reserve will treat you for a small amount of your time. An Army
Reserve Medical Counselor can tell you more, call collect ;
800-USA-ARMY
ARMY RESERVE MEDICINE. BE ALL YOU CAN BE:
Do the
"Write^^
Thing!
We're always looking for interesting and informative
articles for The Journal. If you have a topic that you
think would be of interest to your peers, please submit it
for consideration to:
Managing Editor
The Journal of the Arkansas Medical Society
P.O. Box 55088
Little Rock, AR 72215-5088
(501)224-8967 (800)542-1058
MEDICAL - PATIENT
TREATMENT COORDINATOR
IMMEDIATE OPENING - For M.D. or D.O.
Outpatient Physical Rehab Center in Jonesboro,
Arkansas. Full time or part time. No evenings or
weekends. Salary negotiable. Reply:
Summit Management
P.O. Box 2654
Jonesboro, AR 72402
Volume 93, Number 6 - November 1996
305
Weslem Wildlife
As Faitrniers moveil Wrsi. pioneers C
foiind,aninnuls as exotir as ilie tandvjl^---
buffalo, prairie dogs, bears, faeaverf/tighorff' ' Vl
ilirep, cougars, wolves and rattlesrftiMs.
The eagle becan^ a national s^Tnboi. <i : \ •
thankyouP^^^
m
have a
yi 1 had no
. j did not
„ll,Yourpr‘
,ssibtefo’-"'‘
there else to
.ealnethere^
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^^fontion,
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oeople to p
" Medical
blessed Wit,
y^Pf'ogram.
'^^ndhelpfui
^e.
ror mdre
information
on how
you can help,
caHAHCAFat
(501) 221-3033
or (800) 950-823
Arkansas Health Care
Access FoundatiMi, Inc.
those physiciam who volunteer ^
P through the Arkansas Health |
I Care A ccess Foundation, \
I Thank You!
Y As you can see from d sampling of
II letters we have received, your
Wk involvement in our program is i
■k appreciated and in many jm
||h cases life-saving, fdj/KKk
THANK YOU FOR MAKING THE DIFFERENCE!
In Memoriam
William Joseph Roberts, M.D.
Dr. William Joseph Roberts, of Charleston and formerly of
Waldron, died Monday, October 7, 1996. He was 59. He is survived
by four sons, Joseph Keith Roberts of Cordova, Tennessee, Bradley
Baber of Barling, Arkansas, Travis Bruce Roberts of New Orleans,
Louisiana, and Justin Wade Roberts of Clearwater, Florida; one daugh-
ter, Rachael Bentley Roberts of Fort Smith, Arkansas; two grandchil-
dren, Joseph Barrett Roberts and Mariel Elizabeth Roberts; and one
sister, Della Jane Hill of Navarra, Florida.
Volume 93, Number 6 - November 1996
307
Things To Come
December 4
ARKANSAS LOCATION!
How to Run a More Profitable Practice. Little
Rock Hilton, Little Rock, Arkansas. Sponsored by the
Arkansas Medical Society. For more information, call
(501) 224-8967 or 1-800-542-1058.
December 6-7
7th Incontinence Update; Urogynecology &
Urodynamics Seminar and Interactive Workshop with
(Optional) Post-Conference Clinical Workshop. Hyatt
Regency, New Orleans, Louisiana. Sponsored by
Tulane University School of Medicine Department of
Urology, Nursing Resource Center and Office of Con-
tinuing Medical Education. For more information, call
(504) 588-5466 or 1-800-588-5300.
December 7
Cardiology Seminar. Washington University Medi-
cal Center, St. Louis, Missouri. Sponsored by the Of-
fice of Continuing Medical Education, Washington Uni-
versity School of Medicine. For more information, call
1-800-325-9862.
February 9-14, 1997
Advances in Imaging: 1997. Manor Vail Lodge,
Vail, Colorado. Sponsored by the Departments of Ra-
diology at Tulane University Medical Center and Loui-
siana State University School of Medicine. For more
information, call (504) 588-5466 or 1-800-588-5300.
April 4-5, 1997
Clinical Pulmonary Update. Washington Univer-
sity Medical Center, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 10-12, 1997
Refresher Course & Update in General Surgery.
The Ritz-Carlton Hotel, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
February 8-10, 1997
12th Annual Mardi Gras Anesthesia Update in
New Orleans. Westin Canal Place Hotel, New Orleans,
Louisiana. Sponsored by the Department of Anesthe-
siology & Center for Continuing Medical Education,
Tulane University Medical Center. For more informa-
tion, call (504) 588-5466 or 1-800-588-5300.
308
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Keeping Up
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category I of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Spine Center Conference, 1st Wednesday, 7:00 a.m.. Southwestern Bell/Arkla Room. Light Breakfast provided.
Urology Grand Rounds, September 17th and November 5th, 5:30 p.m.. Southwestern Bell/Arkla Room, Refreshments provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
As an organization accredited for continuing medical education by the Accreditation Council for Continuing Medical Education, the
University of Arkansas for Medical Sciences certifies the following continuing medical education activities meet the criteria for Category I
of the Physician's Recognition Award of the American Medical Association.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand RoundsIM&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Volume 93, Number 6 - November 1996
309
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Fetal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan, - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hosfntal Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Gonference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Ghest Gonference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Gonference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Gonference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology/ Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
310
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical CenterJONESBORO-AHEC NORTHEAST
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/ Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital CME Conference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Gynecologic Malignancies, 3rd Thursday every other month, 7:00 a.m., various area hospitals
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 6 - November 1996
311
Advertisers Index
Advertising Agencies in italics
AMS Benefits 271
Arkansas Children's Hospital inside back
Autoflex Leasing inside front
Care Network 290
The Alan Rothman Company, Inc.
Consumer Quote USA 288
Freemyer Collection System 268
The Medical Protective Company 280
Williams Marketing Services
Riverside Motors, Inc 278
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory back cover
Strategic Marketing
State Volunteer Mutual Insurance Company 266
The Maryland Group
Southwest Capital Management 273
Marion Kahn Communications, Inc.
U.S. Air Force 301
BJK&E Specialized Advertising
U.S. Air Force Reserve 265
HMS Partners, Inc.
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H£ALTH sciences library
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Volume 93 Number 7
December 1996
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THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
ObstetricsIGyuecology
luterml Medicine
Surgery
Family Practice
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EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
Volume 93 Number 7
December 1996
CONTENTS
FEATURES
316 The Sure Proof
Editorial
Lee Abel, M.D.
319 Medicine in the News
Health Care Access Foundation Update
hihoraton/ Achievement Program for Waived/PPM Laboratories Introduced
AMA Reaffirms Commitment to Access to Quality Care for All
104th Congress Concludes With a Flurry of Legislative Activity
Election Update: 12 Physicians/ Spouses in 105th Congress
325 New Member Profile
Roy M. Blackburn, M.D.
327 Changes in Galactosemia Screening Program
Scientific Update
Robert West, M.D.
329 Pseudomembranous Colitis
Scientific Article
William E. Golden, M.D.
Nena Sanchez, M.S.
Beth Pitts, M.D.
333 A Pulmonary Monitoring and Treatment Plan for Children
with Duchenne-type Muscular Dystrophies
Scientific Article
Robert Hughes Warren, M.D.
Sheila Horan Alderson, B.S.
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
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Journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
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$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
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Arkansas Medical Society. The Journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1996 by the Arkansas Medical Society.
339 Aggressive Mismanagement
Loss Prevention
}. Kelley Avery, M.D.
355 1996 AMS Membership Roster
DEPARTMENTS
322 AMS Newsmakers
340 Cardiology Commentary & Update
344 State Health Watch
346 New Members
348 In Memoriam
349 Radiological Case of the Month
351 Things to Come
352 Keeping Up
Cover photo was taken in Northwest Arkansas by A.C. Haralson of the Arkansas Department of
Parks & Tourism.
Editorial
The Sure Proof
Wine is sure proof that God loves us and wants us to he happy.
Benjamin Franklin
Lee Abel, M.DA
On January 2, 1996, the Federal Government re-
leased the 1995 Dietary Guidelines for Americans. This
report which is issued every five years by a committee
appointed jointly by the Agriculture Department and
the Department of Health and Human Services, gives
advice about diet and health. Probably the most con-
troversial departure from the 1990 guidelines, was the
acknowledgment that alcohol consumption may be
healthful.
This significant change apparently occurred only
after a great deal of discussion. The growing body of
data that links moderate alcohol consumption with
certain health benefits was felt too persuasive to ig-
nore. Dr. Marion Nestle, the chairwoman of the de-
partment of nutrition and food studies at New York
University and a member of the committee, said "It is
a triumph of science and reason over politics."^
The report, which does not encourage drinking
and emphasizes the significant harm that more than
moderate alcohol consumption can cause, goes on to
state that "alcoholic beverages have been used to en-
hance the enjoyment of meals by many societies
throughout human history."’ The British government
has been prompted by the growing scientific evidence
to go a step further. In a recent report from the British
Department of Health, it was suggested that middle-
age and elderly men and postmenopausal women who
abstain from alcohol should consider moderate drink-
ing in order to reap the health benefits of alcohol.^
Our understanding of how these benefits come
about is limited. Ethanol has long been thought to be
the primary protective factor, perhaps through its ef-
fect on HDL and LDL cholesterol and fibrinolytic fac-
tors. However, there is evidence that not all alcoholic
beverages are equally beneficial. For example, a large
study in California showed a decreased coronary ar-
tery disease mortality in wine drinkers compared to
drinkers of beer and liquor (who had a lower coronary
* Dr. Abel specializes in internal medicine and is affiliated with
the Little Rock Diagnostic Clinic. He is a member of the edi-
torial board for The Journal of the Arkansas Medical Society.
mortality than nondrinkers). Such factors as age, sex,
weight and smoking were controlled for, but other
factors such as diet, exercise and psychological traits
were not. Because of this "inability to control for all
confounders" the researchers were unable to conclude
that wine definitely conferred more protection.^
Probably the most intriguing study is a well done
one from Denmark which generated much publicity
because of its striking findings. In this study, wine
drinking, but not consumption of beer or distilled spir-
its, was associated with a large reduction in cardiovas-
cular, cerebrovascular, and all cause mortality. Daily
beer consumption (up to 3 to 5 drinks a day) caused
no change in the mortality rate compared to nondrink-
ers, while more than two drinks of liquor a day in-
creased the death rate. The authors of this study point
out that their data "suggests that other more broadly
acting factors in wine may be present. Antioxidants
and flavonoids, which are presumed to prevent both
coronary heart disease and some cancers, may be
present in red wine. It has also been suggested that
tannin and other phenolic compounds in red wine may
have a protective effect."'*
Tve noticed that I tend to believe studies that sup-
port my prejudices, and so I find the Danish study
important. Wine at its core is an elegantly simple and
natural beverage. To make wine all one really does is
crush grapes. The winds bring yeast which settle on
the skin of the grape. When the grape is crushed, the
yeast on the outside is brought into contact with the
sugar on the inside; fermentation then begins apd wine
is created. Wine is basically preserved fruit. Is it pos-
sible that a glass of wine can be counted as one of the
recommended 5 daily servings of fruit and vegetables?
Considering the health risks associated with consum-
ing red meat, should it be eaten only when accompa-
nied by the antidote, a glass of red wine? It will be
interesting to see if wine's place in our "dietary phar-
macopoeia" becomes established, along with such
therapeutic agents as broccoli, sweet potatoes and garlic.
Though it remains far from being scientifically
316
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
proven to have special beneficial effects, wine really is
one of our oldest medicines. Culturally and histori-
cally wine has always been seen as unique among bev-
erages, having salutary effects for both body and mind.^
The Greeks and Romans had a God of Wine (Dionysis
and Bacchus respectively). The Judeo-Christian tradi-
tion is tied even more closely to wine. My introduc-
tion to the central role of wine in Judeo-Christian the-
ology came from Jeff Smith, who hosted the popular
PBS television series "The Frugal Gourmet," and is
the author of numerous cookbooks. He is not your
average chef. In fact, he is an ordained Methodist min-
ister, and in the great love he shows for wine, food,
people and life, he must surely be doing God's work still.
The references to wine in the Old Testament are
numerous, since wine played an important role in Jew-
ish custom and life. Jeff Smith notes that the first thing
Noah planted after the flood was a vineyard, because
wine was needed to give proper thanks to God. One
tradition is the Kiddush which is a blessing said over
a cup of wine. In Jeff Smith's book "The Frugal Gour-
met Cooks With Wine," in a chapter titled "The Sure
Proof" he explains:
To this day every Jewish service opens with the Kiddush.
There seems to be an unasked question on the floor of the
Temple, a question that need not he asked. Nevertheless the
answer is given. The question? "Just how clever is this god
that you worship?" The answer? "Blessed art thou, O Lord
God, King of the Universe, Creator of the Fruit of the Vine. "
That settles the discussion! Only the Lord could have come
up with something as blessed as wine. Biblically wine was
always seen as a sign of the cleverness of the Creator.^
Hugh Johnson in "Vintage: The Story of Wine,"
writes that "The Israelites' interest in wine-growing is
a continual theme of the prophets. Isaiah contains
advice of planting a vineyard; Amos and Joel, Jeremiah
and Ezekial, Zachariah and Nehemiah all use the vine
as a symbol of a happy state. Indeed, in the whole of
the Old Testament only the Book of Jonah has no ref-
erence to the vine or wine."^
For Christians, too, wine has played a central role.
Recall that the very first miracle of Jesus' ministry was
at the wedding in Cana when Jesus changed water
into wine. And the story also specifically mentions
that Jesus made good wine! (John 2:1-11). In a con-
versation I once had with my Methodist minister about
Christianity and wine, he pointed out that Jesus en-
joyed the "community of the table" and was criticized
as being a winebibber and glutton (Matt 11:19 and Luke
7:34). Jesus' table was inclusive, he would break bread
and drink wine with all.
Jesus also asked to be remembered in a ceremony
where wine is a key element. St. Thomas Aquinas
wrote "The Sacrament of the Eucharist can only be
performed with wine from the vine, for it is the will of
Christ Jesus, Who chose wine when He ordained this
sacrament... and also because the wine is in some sort
an image of the effect of the Sacrament. By this, I mean
spiritual joy, for it is written that wine makes glad the
heart of man."* ’ Paul recognized the healing qualities
of wine when he advised "No longer drink only wa-
ter, but use a little wine for the sake of your stomach
and your frequent ailments" (1 Timothy 5:23). Wine is
so integral a part of the Bible that Oxford Professor
Hanneke Wirtjes writing in "The Oxford Companion
to Wine" states that "The Bible is not suitable reading
for teetotallers."’”
Though wine has been exalted in scripture and by
poets through the ages as a source of beauty and joy,
it is also true that in excess all alcoholic beverages can
cause great pain and tragedy. Religions have dealt with
this inherently two-sided nature of alcohol in differ-
ent ways.” Islam for instance prohibits use of alcohol.
Some Protestant denominations, especially since the
temperance movement of the late 1800's, have moved
away from the traditional Christian position and em-
braced prohibition against all alcohol, including wine.”
This dark side of alcohol poses a dilemma for us
as physicians and as parents. As physicians, we are
very familiar with the dose effect. One digoxin tablet a
day may help, but several a day may kill. Likewise for
alcohol; however, alcohol can be associated with ad-
dictive behavior and herein lies the concern. Should
we avoid recommending something healthful, for fear
someone might abuse it? Physicians don't hesitate to
advise exercise yet it can be done excessively and harm
the patient's health. Part of the difference is that alco-
hol is a very emotionally charged issue and is often
seen in moral terms.” This is coupled with the fact
that alcohol abuse is a very common, yet incompletely
understood problem.
I remain reluctant to recommend wine to my pa-
tients. People have many good reasons for not drink-
ing, and for certain conditions the risks of drinking
outweigh the potential benefits. Primarily, I am con-
cerned about violating the physicians' dictum of
Primum Non Nocere (First do no harm). On the other
hand, one could point out that my attitude is pater-
nalistic and unscientific. There is no evidence that rec-
ommending wine in moderation to achieve health ben-
efits will increase the amount of alcohol abuse. Per-
haps, we should educate our patients about the ben-
efits as well as the risks, and as usual in medicine
always carefully individualize any advice. Given how
devastating alcohol abuse can be, caution seems rea-
sonable.
As parents, whether we drink or not, we have the
responsibility of helping our children make good
choices about alcohol. Alcohol abuse plays a role in
the deaths of too many of our teenagers and young
adults. There is some suggestion that children raised
in a household where alcohol is consumed moderately
are less likely to abuse alcohol than children raised in
an abstinent home. But whether this is true or not.
Volume 93, Number 7 - December 1996
317
the family influence is only one of many. Peer pres-
sure, media portrayals of alcohoP'* and advertising also
play a role. 1 hope my daughter and son, if they choose
to drink as adults, will learn to appreciate wine re-
sponsibly. In this, the challenge posed by alcohol is
similar to much else in life. Work, sex, money and
other blessings can be associated with excessive be-
havior and destructive consequences. The challenge
is to keep things in balance and appropriate, to use
good judgment and moderation.
Thomas Jefferson said "Good wine is a necessity
of life." It certainly adds a dimension to life that I find
enjoyable. The history of wine is fascinating, and wine
helps remind us of the wonder and mystery of life.
Jeff Smith notes that wine is a symbol of community;
a fine bottle of wine immediately makes us consider
with whom to share it. There can be something quite
magical about sharing a bottle of wine with friends
around the "community of the table."
Not wanting to sound pretentious, I could simply
state that sipping a glass of wine with a meal really
does "taste great and is less filling." More people would
probably enjoy wine were it not surrounded by so
much pretense and snobbery. Such attitudes are off-
putting to others, yet I would have to admit to having
given as well as received. Pretense and snobbery re-
flect our insecurity; it is a misguided attempt to feel
good about ourselves by acting superior to others by
virtue of our knowledge or possessions.’^
In past centuries there was a lot of bad wine
around. Nowadays, one doesn't have to study and
know a lot about wine to drink good wine. I am a fan
of California wine, and it seems to me that the quality
of California fruit is so good and wine making skills so
high that it's actually somewhat difficult to find a bottle
of bad wine. And if we do, it simply helps us appreci-
ate all the good ones more. And a good bottle of wine
is defined as one that you like.
Life is short; no one can experience all the good
things life has to offer. But if you are acquainted with
the joys of wine, then when you lift your glass of wine
this holiday season, let your heart be filled with thank-
fulness for the gift of wine and for the gift of life.
Whether future scientific studies confirm the special
beneficial qualities of wine or not, you can be sure
that such feelings of gratitude are good not only for
your mind and body, but also for your soul.
Notes:
1. Burros M. In an About-Face, U.S. Says Alcohol Has Health
Benefits. New York Times. January 3, 1996: Al, B6.
2. Matthews T. Britain Raises Safe Drinking Limits. Wine
Spectator. February 29, 1996:9.
3. Klatsky AL, Armstrong MA. Alcoholic Beverage Choice
and Risk of Coronary Artery Disease Mortality: Do Red Wine
Drinkers Fare Best? Am. Journal of Cardiology 1993; 71:467-469.
4. Gronbaek M, Deis A, Sorensen T, Becker U, Schnohr P,
Jensen G. Mortality associated with moderate intakes of wine,
beer, or spirits. British Medical Journal 1995;310:1165-1169.
318
5. There is also some current evidence that alcohol has health-
ful effects on the mind. Dr. Liz Applegate of the University
of California at Davis writing in the May 1995 issue of
Runner's World refers to a study which "tracked the drink-
ing habits of nearly 4,000 twins for 20 years (and) found that
those who drank one to two drinks daily maintained better
reasoning powers, problem solving and other mental skills
than those who abstained."
6. Smith J. The Frugal Gourmet Cooks With Wine. New York:
William Morrow, 1986, p. 75.
7. Johnson H. Vintage: The Story of Wine. New York: Simon
and Schuster, 1989, p. 76.
8. Johnson H. p. 81.
9. The scripture St. Thomas Aquinas refers to is Psalms 104:15
"wine maketh glad the heart of man."
10. Robinson J, ed. The Oxford Companion to Wine. Ox-
ford: Oxford University Press, 1994, p. 112.
11. Kesby J. Oxford Companion, p. 787.
12. The temperance movement in the United States began
by urging just that, temperance, but later endorsed total
prohibition. Likewise, the movement's original target was
distilled spirits, but it later came to include beer and wine.
The movement culminated in the passage of the 18“' Amend-
ment in 1920 which prohibited "the manufacture, sale, or
transportation of intoxicating liquors." No compensation was
provided for by the Amendment; most of the California win-
eries, which had been flourishing, were forced to go out of
business. Some few managed to stay in business by produc-
ing "sacramental wine," the demand for which greatly in-
creased during prohibition. See Prof. Thomas Pinney in
Oxford Companion, p. 762.
13. Fitzgerald F. To Your Health? Internal Medicine News.
March 15, 1995:14.
14. Dr. Jerry Avorn an associate professor of medicine at
Harvard Medical School in a letter to the editor in the Au-
gust 6, 1996, New York Times writes that although candi-
date Bob Dole saw the movie "Independence Day" and "pro-
claimed it to be the kind of good-values movie Hollywood
should be producing for the nation's families" he wonders
about Senator Dole's assessment. Dr. Avorn explains: "The
daredevil pilot who saves humanity by maneuvering his jet
brilliantly though the aliens' defenses does so while drunk,
his alcoholic stupor turned into awesome agility by many
cups of strong coffee. The other hero is a lovable under-
achiever who devises an ingenious plan to defeat the invad-
ers only after his reasoning powers get a fifth or so of lubri-
cation. I am not opposed to the enjoyment of alcohol or its
depiction on screen... But isn't it thoughtless, in a film clearly
for pre-teens and adolescents, to have heroic acts appear to
depend on alcohol? The plot could have worked as well or
better" with other scenarios and "our understanding of hero-
ism might have been broadened, instead of cheapened."
Dr. Avorn goes on to note that "politically correct art can be
terrible" but he questions if it's a "good idea to make a movie
for children showing that driving skill and brilliant reason-
ing are the consequences of getting drunk."
15. Wine snobbery is very old. Some have suggested that it
began during the Roman Empire when wine was seen as
the drink of the noble and civilized Romans while beer or
ale was the drink of the Gauls who were seen by the Ro-
mans as uncivilized barbarians. Francophiles, however, point
to the evidence that suggests that vineyards were present
and wine was being made in the region of France before the
Romans arrived there.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Medicine in the News
Health Care Access Foundation
As of November 1, 1996, the Arkansas Health Care
Access Foundation has provided free medical service
to 11,833 medically indigent persons, received 22,312
applications and enrolled 43,507 persons. This program
has 1,756 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
Laboratory Achievement Program for
Waived/PPM Laboratories Introduced
A new Laboratory Achievement program, which
features educational products and a Certificate of
Achievement for laboratories or other facilities involved
with Waived or Provider-Performed Microscopy (PPM)
testing, was unveiled by the Commission on Office
Laboratory Accreditation (COLA) October 30, 1996. The
development of the program is in response to
healthcare professionals desiring to demonstrate qual-
ity through continuing education and quality testing
to ensure excellent patient care.
The Laboratory Achievement program includes:
^Preparation of the Health Care Financing Adminis-
tration (HCFA) forms necessary for a new Waived/PPM
certificate for the Laboratory Director's signature,
^Individualized Procedure Manual based on the
facility's test menu,
^Quality Control and Quality Assurance forms,
^Quality Assurance Plan,
^Training Guides for testing personnel,
*COLA's OSHA Guide to Bloodborne Pathogens booklet,
*Two-year subscription to bi-monthly newsletter,
COLA Update,
"^elf-Assessment Questionnaire for Waived/PPM testing,
^Evaluation of the completed Self-Assessment Ques-
tionnaire,
“^Personalized, step-by-step feedback on how to im-
prove the laboratory practices based on the Self-As-
sessment, and
“^Access to cola's Customer Service technical
hotline.
The Laboratory Achievement program is valuable
to physician office laboratories, ambulatory surgical
centers, community clinics, hospital-affiliated labora-
tories, industrial laboratories, managed care facilities,
student health services, home health agencies, hos-
pices, skilled nursing facilities and other point-of-care
testing facilities.
J. Stephen Kroger, M.D., F.A.C.P, COLA's Chief
Executive officer states, "Testing facilitates need a com-
petitive advantage as third party payers and consum-
ers alike are demanding quality. COLA will be among
the first to provide recognition to excellent laborato-
ries performing testing at the Waived and PPM levels.
As one of the leading accreditation organizations in
the country, COLA made the decision to fill this gap
with a program that enables a testing facility to be a
leader in healthcare."
Information on COLA's Laboratory Achievement
program, as well as other physician and laboratory
services, is available by calling 1-800-981-9883.
AMA Reaffirms Commitment to Access to
Quality Care for All Statement attributable to:
Daniel H. Johnson, Jr., MD, AMA President
"The AMA welcomes the Kaiser Family Founda-
tion study on uninsured Americans, published in
JAMA October 25, 1996. It makes an important contri-
bution to our understanding of the uninsured popula-
tion and demonstrates that it is critical to monitor the
state of access to health care in America on a continu-
ing basis.
"The AMA is committed to access to health care
for the uninsured. Universal access continues to be
our ultimate goal. We celebrated a positive step to-
ward that goal when the Kassenbaum-Kennedy bill,
which assures insurance portability for workers chang-
ing jobs and continued coverage for patients with
pre-existing conditions, was signed into law earlier this
year. Other incremental steps will need to be taken
next Congress.
"Meanwhile, in order to keep the insured prob-
lem to a minimum, we are committed to Medicare re-
form, to preserve the program for all generations, and
Medicaid reform, to provide a necessary safety net for
the needy and most vulnerable in our society.
"There is no easy solution to the problem of the
uninsured. However, there are many current AMA
policies we would like to see implemented to ease the
problem. For example, we would like to see an exten-
sion of employer-provided insurance coverage for up
to four months following unemployment. And because
many of the uninsured are young adults, we encour-
age the health insurance industry and employers to
make extended health coverage available under the
parents' family policy until age 28.
Volume 93, Number 7 - December 1996
319
"Finally, our commitment to charity care contin-
ues. In 1994, the physicians of America contributed
$21 billion in charity care to their patients who needed
it most and will continue to donate their services in
order to increase access to medical care for the unin-
sured. While the problems of the uninsured will not
be solved overnight, we believe the ultimate goal of
universal access must be achieved - one step at a time."
Information provided by AMA Fed-Net.
104th Congress Concludes With a Flurry
of Legislative Activity; Solid Gains for
Medicine and Patients - Groundwork Laid
for Further Gains in 1997
In early November, the 104th Congress adjourned
for the remainder of the year after concluding its work
on a variety of appropriations bills and several other
outstanding issues. The legislative and regulatory suc-
cesses of the AMA during the last two years make this
one of the most meaningful Congresses in recent his-
tory. These include:
ANTITRUST RELIEF: Coming on the heels of an
aggressive legislative campaign which was initiated and
sustained by the AMA's work with Rep. Henry Hyde
on HR 2925 (the Antitrust Health Care Advancement
Act of 1996), the Federal Trade Commission on Au-
gust 28th issued their "Statements of Antitrust En-
forcement Policy in Health Care." The enactment of
these new guidelines will provide physicians with a
rich source of tools to form different kinds of networks
in order to respond to the many changes which have
taken place in the health care marketplace. At the time
these new guidelines were released, the AMA had
secured more than 150 sponsors for HR 2925, and the
bill had been approved overwhelmingly by the House
Judiciary Committee and was awaiting consideration
by the full House of Representatives.
FEDERAL HEALTH INSURANCE REFORMS: The
Congress and President this year enacted the so-called
Kassebaum-Kennedy health insurance reform law
which: 1) extends to patients portable insurance cov-
erage, 2) provides guaranteed issue for small busi-
nesses, 3) places limits on restrictions based upon pre-
existing medical conditions, and 4) includes a demon-
stration project to determine the effectiveness of Medi-
cal Savings Accounts (MSAs). While the legislation is
not a cure-all for our health care system's ills, it does
lay the groundwork for an improved health care deliv-
ery system and for future legislative action.
FRAUD AND ABUSE: Contained within the pro-
visions of the Kassebaum-Kennedy legislation are new
tools to assist government agencies to catch truly
fraudulent health care providers while ensuring that
providers who make innocent mistakes or billing er-
rors will not be unfairly punished. Criminal allega-
320
tions must be proven to be knowing and willful viola-
tions of the law. Similar standards apply to the impo-
siHon of civil monetary penalties. In addition, the AMA
won the right for physicians to obtain binding advi-
sory opinions to determine in advance whether or not
a particular business arrangement is in compliance with
these new, complex fraud and abuse statutes.
ADVISORY COMMISSION ON CONSUMER
PROTECTION AND QUALITY: Over the last few
years, the AMA has fiercely pursued an agenda which
heightens governmental awareness of the need for
patient protections in the new era of managed care. In
August, President Clinton announced the formation
of the President's Advisory Commission on Consumer
Protection and Quality in the Health Care Industry.
The President's charge to this Commission is for it to
assess changes occurring in the health care system and
"recommend measures that may be necessary to pro-
mote and assure health care quality and value, and
protect consumers and workers in the health care system. "
MENTAL HEALTH INSURANCE COVERAGE
PARITY: As part of the final push toward closure of
the Second Session of the 104th Congress, the House
and Senate agreed to an amendment, since enacted,
which will require that aggregate and annual payment
limits on insurance policies be the same for mental
and physician illnesses for all health plans that pro-
vide mental health benefits. This requirement will go
into effect on January 1, 1998. This so-called "mental
health parity" amendment represents a strong first-step
toward equalizing such coverage and providing some
financial protections to those individuals who suffer
from chronic or catastrophic mental conditions.
"DRIVE-THROUGH DELIVERIES": This year, the
Congress also agreed to legislation which will prohibit
the insurance company practice known as
"drive- through deliveries." Under the new law, the
decision as to how long a mother and her newborn
child will remain in the hospital will be made by the
mother and her physician. This new law represents a
strong first-step by the federal government toward
assuring that cost containment will not be allowed to
be the primary or sole consideration in determining
how and which health care services will be paid for in
the new era of "managed care."
CURBING YOUTH SMOKING: Since 1989, the
AMA has been involved in a national campaign com-
bating youth smoking and has tried to heighten the
public's and the government's understanding of the
need to regulate tobacco in order to curb the industry's
promotion, marketing and sales efforts which are aimed
directly at children. This summer. President Clinton
announced a series of measures intended to educate
children on the hazards of smoking and to make it
more difficult for children to gain access to cigarettes.
These new rules also will regulate tobacco advertising
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
which is geared toward children in an attempt to re-
duce the appeal of smoking.
MEDICAL RESEARCH: Even during this era of
fiscal belt-tightening, the AMA has been aggressively
pursuing additional federal funds for medical research.
We are very pleased that the National Institute of
Health (NIH) received an increase in its budget for
medical research for the 1997 Fiscal Year. The AMA
also played a key role in preserving federal funding
for the Agency for Health Care Policy and Research
(AHCPR).
METHOD PATENTS: Working with a coalition of
medical specialty groups, the AMA helped craft an
agreement with pharmaceutical and biotechnology
groups on compromise language which was enacted
into law clarifying that physicians may not be sued for
patent infringement in this area.
GAG CLAUSES: Finally, legislation to ban "gag
clauses" in physician contracts also saw a great deal of
discussion and debate during the 104th Congress,
thanks, in great measure, to Iowa Congressman Greg
Ganske, MD. This legislation would make it unlawful
for any health plan to interfere with or restrict medical
communications between physicians and patients and
would prohibit health plans from taking any adverse
action against a physician on the basis of a medical
communication between a physician and his or her
patient. Enactment of "anti-gag" legislation by the
Congress early next year would demonstrate its com-
mitment to protecting patients without disrupting le-
gitimate managed care utilization management and
quality assurance activities. - Information provided by
AMA Fed-Net.
Election Update: 12 Fhysicians/Spouses in
105th Congress
Late elecHon returns indicated that incumbent Rep.
Nancy Johnson (R, Connecticut) a physician's spouse,
narrowly won re-election with 113,022 votes to her
opponent's 110,840. Her victory means 12 physicians
and physicians spouses will serve in the US House of
Representatives in the 105th Congress, joining Sen.
William Frist (R, Tennessee) who was elected in 1994.
The other winners:
* Vic Snyder, MD (D, Arkansas)
* Xavier Becerra, spouse, (D-California) incumbent
* Dave Weldon, MD (A-Florida) incumbent
* Greg Ganske, MD (A-Iowa) incumbent
* John Cooksey, MD (A-Louisiana)
* Marge S. Roukema, spouse (R-New Jersey) incumbent
* Tom Coburn, MD (A-Oklahoma) incumbent
* Ron Paul, MD (A-Texas)
* Tom Davis, spouse (D-Virginia) incumbent
* James McDermott, MD (D- Washington) incumbent
* Barbara Cubin, spouse (R-Wyoming)
In referendum and initiative voting around the
nation, California voters rejected to propositions that
would have imposed new controls over health main-
tenance organizations. Voters in California and Ari-
zona approved the legalization of marijuana for medi-
cal uses. - Information provided by AMA Fed-Net.
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AMS Newsmakers
Dr. John E. Alexander Jr., of Magnolia, was in-
stalled as president of the Arkansas Academy of Fam-
ily Physicians at its Annual Scientific Assembly in Little
Rock recently.
Dr. Shabbir A. Dharamsey, a Pine Bluff cardiolo-
gist, has been elected to serve as a member of the
American Heart Association Board of Directors for the
Arkansas Affiliate.
Dr. John Richard Duke, chief resident at the De-
partment of Family and Community Medicine at
UAMS, is among 20 recipients nationwide of a $2,000
award from the American Academy of Family Physi-
cians to help finance his graduate medical training in
family practice. He was selected from a field of 157
candidates on the basis of scholastic achievement, lead-
ership qualities, community involvement and exem-
plary patient care.
Dr. W. Ducote Haynes, a radiation oncologist and
medical director at CARTI/Searcy, recently retired af-
ter 20 years of practicing at CARTI. He was one of the
first physicians at CARTI in Little Rock when the facil-
ity opened in 1976.
Dr. P. Reddy Tukivakala, a physician of internal
medicine in Helena, has been elected by the Board of
Directors of the Delta Health Alliance, a local man-
aged care physician/hospital organization, to serve as
president of the organization until December 1997.
Dr. Herbert Wren, a Texarkana retired thoracic and
vascular surgeon, was recently elected president of the
Tulane University Surgical Society. Dr. Wren, who is
now a Methodist minister, practiced medicine for forty
years.
Send your accomplishments and photo for
consideration in AMS Newsmakers to:
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
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JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Roy M. Blackburn, M.D.
PROFESSIONAL INFORMATION
Specialty: Physical Medicine and Rehabilitation
Years in Practice: Three
Office: Texarkana, Texas
Medical School: American University of the Caribbean,
Montserrat, British West Indies, 1987
Internship: St. Vincent's Medical Center, Staten Island, NY, 1988
Residency: Emory University, Atlanta, Georgia, 1993
Affiliates! Organizations: American Academy of Physical Medicine & Rehabilitation, American
Medical Association and Southern Medical Association
PERSONAL INFORMATION
Date/Place of Birth: August 3, 1958, in Jacksonville, Florida
Hobbies: Music and traveling
THOUGHTS & OTHER INFORMATION
If I had a different job, I'd be: In music
Figure I most identify with: Beethoven
Worst habit: Not filling out forms
Best habit: Filling out forms when returned
Behind my back they say: Where's his front?
Most valued material possession: Guitar
People who knew me in medical school, thought I was: Compulsive
The turning point of my life was when: I achieved my second board certification
Favorite vacation spot: Budapest, Hungary
One goal I haven't achieved, yet: Speaking Hungarian fluently
One goal I am proud to have reached: Solo practitioner
Favorite Childhood Memory: My great aunt's tapioca
When I was a child, I wanted to grow up to be: An adult
One of my pet peeves: People who cut to the front of the line
First job: Selling lemonade
Worst job: Being an intern
One word to sum me up: Multifarious
If you would like to appear in New Member
Profile or Member Profile, contact Tina Wade
at AMS at (50 1 ) 224-8967 or 1 -800-542- 1058.
Volume 93, Number 7 - December 1996
325
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Scientific Update
Changes in Galactosemia
Screening Program
Robert West, M.D.*
Arkansas neonates have been screened for galac-
tosemia since January of this year. The primary screen-
ing methodology has consisted of quantitative fluoro-
metric assay for both total galactose and galactose-
1-phosphate uridyltransferase (GALT). Previous re-
ports in The ]ournal of the Arkansas Medical Society have
reviewed the relevant disorders of galactose metabo-
lism and discussed the cutoff values used in the Ar-
kansas screening program. The following summarizes
findings to date and outlines recent changes in proce-
dures and reporting of results.
Between January 1, 1996 and September 30, 1996,
a total of 25,807 satisfactory specimens were received
for initial screening. Of these, 611 were reported as
"partial positive" using the cutoff values in place dur-
ing that period. An additional 24 specimens were re-
ported as "positive," i.e. total galactose of >15 mg/dL,
GALT of <3.5 U/gHb, or both.
Follow-up of the abnormal reports during this pe-
riod resulted in detection of one case of classic galac-
tosemia as well as four probable Duarte variant-classic
galactosemia (D/G) compound heterozygotes. The in-
fant with classic galactosemia had screening results
that were positive for both total galactose and for GALT.
This baby is being followed at Arkansas Children's
Hospital and has had no significant morbidity to date.
As for the presumed D/G infants, three had "positive"
newborn screening results, while the other one had
"partial positive" initial results.
A serious problem throughout the first nine
months of screening was the extremely high number
of partial positive results reported. Raising the cutoff
Robert West, M.D., is a Pediatric Medical Consultant with
the Arkansas Department of Health.
value for total galactose to 10 mg/dL earlier this year
did not sufficiently alleviate the problem. Therefore,
the Department of Health worked with both the Ge-
netics Program at ACH as well as the laboratory sys-
tem manufacturer (Isolab) to develop an innovative
solution. These efforts culminated in changes in screen-
ing cutoffs and methodology that went into effect in
mid-October. Key changes include the following: speci-
mens having total galactose values of 10-15 mg/dL and
GALT values >5.0 U/gHb are now reported as "nor-
mal," while specimens with galactose values in the
same range, but with GALT values of 3. 6-5.0 U/gHb,
are assayed for galactose-l-phosphate (gal- 1-P). A
gal-l-P value of >4 mg/dL defines a "partial positive"
result, while samples with a gal-l-P of less than 4 mg/
dL, galactose 10-15 mg/dL, and GALT 3. 6-5.0 U/gHb
are now reported as "normal."
The gal-l-P assay is performed via the same sys-
tem utilized for galactose, GALT, and phenylalanine
determinations. The Supervisor of the Clinical Chem-
istry Section at ADH was instrumental in modifying
the system to permit gal-l-P testing. Interestingly,
Arkansas is the first state to incorporate automated
filter paper assay for gal-l-P into its galactosemia screen-
ing program, and it appears likely that other states
will follow.
The new screening and reporting system will
markedly reduce the volume of partial positive results
and thereby prevent unnecessary follow-up with its
attendant costs and inconveniences. At the same time,
sensitivity of the screening process is unlikely to be
compromised. Gal-l-P determination should be most
useful in identifying babies at higher risk for signifi-
cant transferase abnormalities, particularly low-activity
variant states.
Volume 93, Number 7 - December 1996
327
Galactose
(mg/dL)
GALT
(U/gHb)
Specimen Integrity
Gal-l-P
(mg/dL)
Interpretation
< 10
> 3.5
Presumed normal
10 - 15
> 5.0
—
Presumed normal
10- 15
3.6-5. 0
< 4.0
Presumed normal
< 15
<3.5
Unacceptable
Any
Inconclusive
10 - 15
3.6-5. 0
>4.0
Partial positive
Any
<3.5
Acceptable
Any
POSITIVE SCREEN
> 15
Any
Either
Any
POSITIVE SCREEN
Interpretation
Normal
Inconclusive
Partial positive
POSITIVE
Action
None
Filter paper repeat
Filter paper repeat; institute lactose-free formula
Immediately institute lactose-free formula; consult with pediatric
geneticist; submit whole blood and urine for confirmatory testing
The table summarizes the revised reporting scheme
as well as recommendations for follow-up. As always,
consultation for individual patients is available through
the Arkansas Genetics Program by calling 320-2966.
Information regarding the newborn screening program
may be obtained by calling Cheryl Battle, State Genet-
ics Coordinator, at 1-800-482-5400, ext. 2189.
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328
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Scientific Article
Pseudomembranous Colitis
William E. Golden, M.D.”^
Nena Sanchez,
Beth Pitts,
Pseudomembranous colitis, also known as
antibiotic-associated colitis (AAC), is a serious condi-
tion which especially afflicts the elderly and the de-
bilitated. It commonly occurs four to nine days after
the start of antibiotic therapy but can occur, in up to
20% of cases, as late as six weeks after receiving such
therapy. This colitis can also be associated with anti-
neoplastic drugs or metabolic insult to the patient. It
commonly affects the rectosigmoid area of the colon
although 10-20% of cases can occur in isolated proxi-
mal segments of the colon.
AAC is not an invasive infection but rather the
result of toxins (Toxin A & B) produced by the organ-
ism Clostridium difficile. C. difficile is a spore forming,
gram positive, obligate anaerobe. It is present as nor-
mal flora in 3% of ambulatory adults, 60-70% of new-
borns, and 10-30% of hospitalized patients: one sur-
vey found 15% of inpatients were asymptomatic carri-
ers of this organism in their stool.
C. difficile can be transmitted nosocomially. The
spores of this organism can serve as fomites in the
environment for months. Enteric isolation procedures
are recommended for all symptomatic patients and
invasive instruments should be cleansed with materi-
als that can deactivate the spores.
Recent literature suggests that stool specimens for
enteric pathogens or ova and parasites rarely yield sig-
nificant findings after the patient has been in the hos-
pital three days. Nevertheless, these laboratory tests
commonly are ordered for patients who develop diar-
rhea while in the hospital. Studies indicate that such
diagnostic efforts are worthwhile in ambulatory pa-
* William E. Golden, M.D., is Principal Clinical Coordinator
of the Arkansas Foundation for Medical Care, Inc., and As-
sociate Professor of Medicine at UAMS.
** Nena Sanchez, M.S., is Senior Statistician at the Arkansas
Foundation for Medical Care, Inc.
*** Beth Pitts, M.D., is an internal medicine resident at UAMS.
Volume 93, Number 7 - December 1996
tients, but they do not make sense for the patients
who have been in the hospital for a relatively brief
period of time. On the other hand, patients who de-
velop nosocomial diarrhea should have these speci-
mens tested for C. difficile toxin which is a more com-
mon entity in patients who are hospitalized.
Not all diarrhea following antibiotic therapy is j!
caused by C. difficile. Antibiotic-associated diarrhea ^
(AAD) is a self limited condition that resolves with 1
fluid and electrolyte support and the cessation of anti- j
biotic therapy. Patients with antibiotic-associated coli- |
tis (AAC), on the other hand, can have high white j
counts, fever, pain, abdominal tenderness and/or a
diminished albumin. Some present with an acute ab-
domen or toxic megacolon without diarrhea. Stools
for white cells are positive in only 30-50% of cases. ‘
Eighty-five percent of patients with AAC have posi-
tive stool cultures for C. difficile, but as noted earlier,
such cultures can be positive in unafflicted patients.
Immunoassays for toxins are present in 95% of pa-
tients with antibiotic-associated colitis. Tissue cytotoxic
assays are more sensitive than counter electrophore-
sis for detecting toxins. Latex agglutination assays for
toxins lack specificity (high false positive rate) and are
only suggestive of colitis, much like a positive stool
culture; these latex agglutination assays should there-
fore be avoided. Difficult diagnostic cases probably
require endoscopy.
Up to 25% of AAC require no therapy. The drug
of choice for mild to moderate episodes is oral met-
ronidazole. This medication is less expensive than oral
vancomycin and avoids development of fecal entero-
coccal resistance to vancomycin which is common af-
ter administration of this drug. IV vancomycin and
metronidazole should be avoided, as intraluminal con-
centration of these medications is not assured. Oral
vancomycin, when used for severe cases, should be
329
jt
Pseudomembranous
Colitis (N=
425)
Treatment
Frequency
Percent
Oral Metronidazole - first agent
252
59.3%
IV Vancomycin
25
5.9%
Oral Vancomycin - first agent
88
20.7%
IV Metronidazole
55
12.9%
Antiperistaltic Agents
47
11.1%
Enteric Isolation
38
8.9%
Diagnostic Techniques’*^
Diagnostic Technique Number of Hospitals
Percent
Immunoassay for Toxins
24
51.1%
Tissue Cytotoxicity
2
4.3%
Latex Agglutination
16
34.0%
Immunoassay for Antigens
5
10.6%
^Thirty (30) hospitals did not report their methods
given at 125 mg. p.o. q.i.d. and not 500 mg. p.o. b.i.d.
This lower dose is as effective as the higher doses and
is less expensive. If necessary, these medications can
be given by NG tube in patients unable to tolerate oral
liquids. For patients with adynamic ileus, oral met-
ronidazole will not work and treatment should focus
on NG vancomycin, vancomycin enemas, and/or IV
vancomycin. Many of these patients fare poorly and
need colonic resection of the affected bowel.
Before the era of antibiotic treatment for AAC,
many patients received binding resins such as
cholestyramine. These agents should be used only in
mild cases and avoided when patients receive oral
vancomycin which binds to the resin. Lomotil and
other antiperistaltic agents should be avoided, lest re-
tained colonic contents pool toxic fluid and worsen
the patient's overall medical condition.
AFMC reviewed charts for 100% of Medicare pa-
tients hospitalized from October 1994 through Sep-
tember 1995 who received a discharge diagnosis of
pseudomembranous colitis (N=425). Eight percent (33)
of these cases did not have diarrhea documented dur-
ing the hospitalization; nevertheless, 30 of these cases
received antibiotic treatment. It appears that these
patients may have received diagnostic tests and treat-
ment without evidence of clinical disease.
Fifty-nine percent (252) received oral metronida-
zole as first line therapy, but 21% (88) received oral
vancomycin as first therapy. Patients with diarrhea who
were treated in larger hospitals were more likely to
receive the preferred oral metronidazole than were
patients treated in facilities with less than 100 beds
(59% vs 40%, respectively, p-value=.01). An additional
330
6% (25) were given IV vancomycin. Thir-
teen percent (55) were treated with IV
metronidazole. Forty-seven cases or
11.5% received antiperistaltic agents
(Lomotil or Imodium) during their
therapy. Only 9% (38) were placed un-
der enteric isolation.
AFMC surveyed the techniques
used to diagnose pseudomembranous
colitis. Twenty-four hospitals used im-
munoassays for toxins. Two facilities em-
ployed the tissue cytotoxicity assay. Six-
teen hospitals of varying bedsize used
the less specific latex agglutination test
and five used antigen immunoassays.
Thirty hospitals did not report on their
diagnostic technique.
Conclusion
1. Pseudomembranous colitis or
antibiotic-associated colitis (AAC) fre-
quently afflicts the elderly and the de-
bilitated. Enteric precautions, used in
only 9% of these cases, can prevent nosocomial trans-
mission.
2. Oral metronidazole is the drug of choice in terms
of effectiveness and cost. It avoids creation of vanco-
mycin resistant enterococci. Only 59% of cases received
this treatment first, and smaller hospitals used this
medication first 40% of the time.
3. Stool culture, latex agglutination and antigen
assay tests can detect carrier status and other cross
reactive markers. Toxin immunoassays and tissue cy-
totoxicity assays are more accurate in diagnosing the
condition.
4. Hospitals could save money and increase diag-
nostic accuracy by adopting the following procedures
for nosocomial diarrhea:
A. Process stool specimens for enteric pathogens
only for patients hospitalized for three days or less.
B. For patients hospitalized for more than three
days, test stool specimens only for C. difficile toxin -
unless hospital conditions indicate an epidemic bacte-
rial event.
5. Positive diagnostic tests without signs of clini-
cal disease can signal carrier status that may not ben-
efit from therapy. In our study population, 30 of 33
cases without diarrhea received therapy. Diarrhea af-
ter antibiotic administration may not reflect AAC but
rather a non-specific antibiotic-associated diarrhea.
Mild cases of this disorder will respond to the elimina-
tion of antibiotics with fluid and electrolyte support.
6. Antimotility agents such as Imodium or Lomotil
should be avoided in antibiotic associated colitis. Eleven
percent of cases in our population received these
agents.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
7. IV metronidazole or vancomycin should be
avoided except in adynamic ileus because luminal pen-
etration of antibiotic is not assured. IV vancomycin is
the preferred agent if parenteral therapy is appropri-
ate. Approximately 20% of cases received intravenous
therapy.
Suggestions
1. Hospitals should review their diagnostic test-
ing for antibiotic-associated colitis (AAC) to reflect sen-
sitivity, specificity and relative costs. Hospitals using
latex agglutination or antigen immunoassays should
consider changing to toxin immunoassay diagnostic
techniques.
2. Hospitals should review patients discharged
with the diagnosis of antibiotic-associated colitis (AAC)
to verify: 1) the presence of colitis as opposed to
antibiotic-associated diarrhea, 2) the appropriate use
of antibiotics, and 3) avoidance of antiperistaltic agents.
Patients without diarrhea might not benefit from test-
ing or therapy.
3. Patients with antibiotic-associated colitis (AAC)
should be placed in enteric isolation.
Bibliography - Pseudomembranous Colitis
*Barbut F, Kajzer C, Planas N, et al. Comparison of three
enzyme immunoassays, a cytotoxicity assay, and toxigenic
culture for diagnosis of Clostridium difficile-associated diar-
rhea. J Clin Microbiology 1993;31 :963-967.
*Bond F, Payne G, Corriello SP, et al. Usefulness of culture
in the diagnosis of Clostridium difficile infection. Eur J Clin
Microbiol Infect Dis 1995;14:223-226.
*Brazier JS. Role of the laboratory in investigation of
Clostridium difficile diarrhea Clin Infect Dis 1993;S228-S233.
*Fekety R. Antibiotic-associated colitis in Mandel GL. Prin-
ciples and Practice of Infectious Disease, Fourth Edition,
Churchill Livingstone, Inc., New York, 1995, pages 978-987.
*Fekety R, Kim-K-H, Brown D, et al. Epidemiology of
antibiotic-associated colitis. Isolation of Clostridium difficile
from the hospital environment. American Journal of Medi-
cine 1981;70:906-908.
*Fekety R, Shah AB. Diagnosis and treatment of C. difficile
colitis. JAMA 1993;269:71-75.
*Gerding DN, Brazier JS. Optimal methods for identifying
Coltridium difficile infections. Clin Infectious Diseases
1993;16(Suppl 4):S439-442.
*Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile
colitis. NEJM 1994;330:257-262.
*Lyerly DM, Krowan HC, Wilkins TD. Clostridium difficile:
its disease and toxins. Clinical Microbiology Review
1988;1:1-18.
*Manabe YC, Vinetz JM, Moore RD, et al. Clostridium difficile
colitus: an efficient clinical approach to diagnosis. Annals of
Int Med 1995;125:835-840.
*Ros PR, Buetow PC, Pantgrag-Brown L, et al. Pseudomem-
branous colitis. Radiology 1996,198:1-9.
*Tacaqchali S, Jamaa P. Diagnosis and management of
Clostridium difficile infection. BMJ 1995;310: 1375-1380.
* Whittier S, Shaprio DS, Kelly WF, et al. Evaluation of four
commercially available enzyme immunoassays for laboratory
diagnosis of Clostridium difficile-associated diseases. J Clin
Microbiology 1993 ;31:2861 -2865.
Bibliography - Nosocomial Diarrhea
*Chitkara YK, McCasland KA, Kenefic L. Development and
implementation of cost-effective guidelines in the laboratory
investigation of diarrhea in a community hospital. Arch In-
tern Med 1996;156 1445-1448.
*Fan K, Morris AJ, Roller L13. Application of rejection crite-
ria for stool cultures for bacterial enteric pathogens. J Clin
Microbiology 1993;31:2233-2235.
*Marx CE, Morris A, Wilson ML, Roller LR. Fecal leukocytes
in stool specimens submitted for Clostridium difficile toxin as-
say. Diagn Microbiol Infect Dis 1993;16:313-315.
*Morris AJ, Muray PR, Roller LB. Contemporary testing for
enteric pathogens: the potential for cost, time, and health
care savings. J Clin Microbiology 1996,34:1776-1778.
*Morris Al, Wilson ML, Roller LB. Application of rejection
criteria for stool ovum and parasite examinations. J Clin Mi-
crobiology 1992;30:3213-3216.
*Siegel DL, Edelstein PII, Nachamkin I, Inappropriate test-
ing for diarrheal diseases in the hospital. JAMA
1990;236:979-982.
*Valenstein P, Pfaller M, Yungbluth M. The use and abuse
of routine stool microbiology. Arch Path Lab Med
1996;120:206-211.
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Scientific Article
A Pulmonary Monitoring and Treatment
Plan for Children with Duchenne-type
Muscular Dystrophies
Robert Hughes Warren, M.D.*
Sheila Horan Alderson,
Abstract
The Pulmonary Medicine Section of the Depart-
ment of Pediatrics of the University of Arkansas for
Medical Sciences has recently developed an associa-
tion with the Muscular Dystrophy Association Clinic
held at Arkansas Children's Hospital. The slowly pro-
gressive, insidious onset of pulmonary problems as-
sociated with Duchenne-type muscular dystrophies
and other degenerative muscle disorders indicated a
need for a aggressive monitoring and treatment plan
for these children and their caregivers. We have de-
veloped a Respiratory Care Handbook for families with
information on the pulmonary consequences of these
diseases including pathophysiology, pulmonary func-
tion tests, respiratory treatments including mechani-
cal ventilatory support, and anticipation and preven-
tion of pulmonary crises. In addition, we have intro-
duced for the physician a formal monitoring and treat-
ment regimen driven by changes in the vital capacity
lung volume. The substance of this plan is presented
in this manuscript.
Introduction
In the state of Arkansas, children with various
forms of muscular dystrophy are followed through
regional Muscular Dystrophy Association (MDA) Clin-
ics in combination with their primary care physician.
The Department of Pediatrics Pulmonary Medicine
Section has recently associated with the MDA Clinic at
Arkansas Children's Hospital. This association has
resulted in identification of a need for these patients
and their families that had not been previously ad-
dressed. The need is a thorough, formal presentation
of and treatment regimen for the inevitable pulmo-
nary consequences of the Duchenne-type muscular
Robert Hughes Warren, M.D., is Professor of Pediatrics and
Chief of Pulmonary Medicine Section at UAMS and Arkan-
sas Children's Hospital.
Sheila Horan Alderson, B.S., is with Pulmonary Function
Laboratory at Arkansas Children's Hospital.
dystrophies and other forms of muscle disease that
affect the cardiorespiratory system.
We have prepared a presentation designed to tar-
get pulmonary issues. We focus on early education
structured in a clinical setting with verbal and written
information about the lungs and the progressive na-
ture of muscle weakness. We emphasize the value of
regular monitoring of pulmonary function. Knowl-
edge can empower families during the difficult course
of this disease and can assist them when choosing
therapy modalities. Crisis management of respiratory
and other late complications can be avoided. Under-
standing and compliance with medical recommenda-
tions can be enhanced with a comprehensive presen-
tation of pulmonary issues. We have produced a Res-
piratory Care Handbook filled with information spe-
cific to the pulmonary needs of a child with chronic,
progressive muscle weakness. This handbook is given
to the families as soon after diagnosis as possible.
The purpose of this manuscript is to describe the
pulmonary pathophysiology of Duchenne-type mus-
cular dystrophy and to present a pulmonary monitor-
ing and treatment plan. We will briefly provide an
historical perspective of scientific study of chronic
muscle disorders and a systematic approach to pul-
monary history and physical examination.
History
The progressive muscle disorders were first stud-
ied in the mid nineteenth century primarily in France
and Germany. W. Erb initially developed the concept
of a group of diseases that were due to primary de-
generation of muscle fiber, rather than secondary to
pathologic change in its nerve supply. A. von
Eulenberg and R. Cohnheim noted the absence of
change in the central nervous system and the pres-
ence of fatty tissue interspersed between the muscle
bundles. The first complete description of pseudohy-
pertrophic childhood muscular dystrophy based on
clinical and histologic studies was presented by a
Volume 93, Number 7 - December 1996
333
French scientist, G.B. Duchenne in 1868. W.R. Gowers
provided the first comprehensive description of
Duchenne's dystrophy in the English language in 1879.
Diagnosis
Accurate diagnosis of muscular dystrophy includes
a carefully obtained history and a well performed physi-
cal and neurological examination. Laboratory tests most
helpful in diagnosis include serum enzyme levels (cre-
atine phosphokinase, aldolase, lactic dehydrogenase,
and glutamic-oxaloacetic and glutamic-pyruvic transami-
nases), electromyography, and muscle biopsy.
Following an accurate diagnosis, the comprehen-
sive management of a child with a chronic neuromus-
cular disorder begins with the development of short
and long term goals. These goals must include the
long term predictions for progressive pulmonary dys-
function that accompanies the natural decline of muscle
power in these children.
Pulmonary Pathophysiology
Duchenne-type muscular dystrophies impose a
restrictive dysfunction of the respiratory system. Pro-
gressive respiratory muscle weakness and mechanical
factors involving the chest wall and spine both con-
tribute to the development of chronic alveolar
hypoventilation, hypoxemia, and inevitably respira-
tory failure.
The restrictive pulmonary dysfunction is defined
by a reduction in absolute lung volumes, including
total lung capacity, vital capacity, functional residual
capacity, and expiratory reserve volume. For children
with Duchenne muscular dystrophy, the vital capac-
ity plateaus usually between 10 and 14 years of age.’
A respiratory management plan is critical to an attempt
to slow the decline of vital capacity which can be as
much as 20% per year for children who do not receive
adequate respiratory treatment.
Chronic alveolar hypoventilation associated with
a primary diagnosis of Duchenne-type muscular dys-
trophy is caused by decreased lung expansion due to
musculoskeletal limitations of the chest wall. As
muscles in the neck, thorax, and abdomen deterio-
rate, the patient will develop a rapid, shallow respira-
tory pattern.^ Decreased lung compliance and
microatelectasis develop quickly in the absence of ef-
fective deep inspirations or mechanically assisted
hyperinflations. Chronic hypoinflation of the lung
leads to alveolar collapse and may result in perma-
nent loss of lung and chest wall elasticity.’’ Further
mechanical deterioration of lung function can occur
with repeated acute respiratory tract infections.
The restrictive lung dysfunction in Duchenne-type
muscular dystrophy can lead to alterations of central
nervous system respiratory control mechanisms.'’ Short
334
periods of oxygen desaturation and hypercapnia oc-
cur usually during REM sleep when ventilatory re-
sponses are diminished. Repeated episodes of hyper-
capnia during sleep can result in significant changes
in blood gas values detected when the patient is awake.
An elevated bicarbonate can be indicative of chronic
renal compensation for nocturnal hypercapnia. Unless
treated, hypercapnia and hypoxemia can lead to the
development of cor pulmonale. Normocapneic hy-
poxemia is common and may be due to decreased oxy-
gen diffusion across the alveolar-capillary membrane
secondary to microatelectasis and pulmonary fibrosis.
It is tempting at this point in patient care to ad-
minister supplemental oxygen to correct the hypox-
emia. However, the primary problem is
hypoventilation, especially during sleep. Continuous
oxygen therapy may depress ventilatory drive, thereby
exacerbating alveolar hypoventilation and hasten res-
piratory decline.® Hyperinflation therapy in the form
of mechanical ventilatory assistance can minimize or
eliminate the periods of hypercapnia and hypoxemia
during sleeping hours.
Therapy Applications
When the vital capacity falls within a range of 75
to 61% of predicted for the patient's current height
and weight, deep breathing exercises using an incen-
tive spirometer can be introduced to sustain inspira-
tory volumes. Mechanically assisted hyperinflation
therapy can be introduced when the vital capacity falls
within a range of 60 to 41% predicted. This therapy
can reverse the alelectatic process and transiently im-
prove pulmonary compliance.
Mechanically assisted volume ventilation by mask
during sleeping hours may be indicated when the vi-
tal capacity falls to 40% predicted or less. As the vital
capacity diminishes, mechanical assistance can be in-
creased as needed during waking hours. Airway con-
nection can range from a simple mouthpiece to a cus-
tom fabricated oral-nasal interface to a tracheostomy
with a Passy-Muir valve for vocalization.^
Significant curvature of the spine develops in many
children with chronic muscle disorders; affecting 90%
of children with Duchenne-type muscular dystrophy
and greater than 90% of children with severe early-
onset spinal muscle atrophies. Corrective spinal sur-
gery can be offered to these patients for the purposes
of straightening the spine. This can result in a decrease
in the rate of decline of the vital capacity from 20%
annually without surgery to 5% annually following
surgery.’’ Spinal stabilization allows the child to main-
tain a comfortable seated position for continued wheel-
chair mobility and prevents a bedridden existence.
Surgery should be performed when the lungs are
at least risk for post-operative pulmonary complica-
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
tions. Other considerations as to the timing of the
surgery are: vital capacity, degree of curvature of the
spine, age of the child, maximum height of the child
at the time spinal stabilization is considered, and the
number of recurrent pneumonias and frequency of
atelectasis.
Pulmonary Evaluation
A thorough pulmonary history must be obtained
soon after diagnosis. Inquiries regarding the newborn
period should include the presence or absence of: pre-
maturity, hyaline membrane disease, oxygen re-
quirements over 30 days in duration, bronchopulmo-
nary dysplasia, number of days on mechanical venti-
latory support, tracheomalasia, laryngomalasia, meco-
nium aspiration, or gastroesophageal reflux.
Inquiries regarding the infancy and early child-
hood period should include the presence or absence
of: recurrent lower respiratory infections, atopy, wheez-
ing, sleep disturbances, gastroesophageal reflux with
aspiration, constipation, upper respiratory infections
related to recurrent ear or sinus infections, age appro-
priate activity, exercise tolerance, active or passive to-
bacco smoke, or exposure to potential environmental
irritants to the lung.
A physical examination with a pulmonary focus
should include: segmental auscultation, visual inspec-
tion of ribcage and abdomen movement with breath-
ing, demonstration of cough effort, examination of
extremities for clubbing, cyanosis, or edema, inspec-
tion of ears, nose, and throat, and visual inspection of
the spine for any curvature.
Pulmonary Function Testing
Objective information regarding the current sta-
tus of the lung should be obtained with pulmonary
function testing (PFT). When data and physical ex-
amination demonstrate a decline, we initiate appro-
priate ventilatory assistance well in advance of poten-
tial pulmonary crises. For children under the age of 5
years who are unable to perform specific ventilatory
maneuvers required for routine spirometry, we obtain
a capillary blood gas, pulse oximetry, negative inspira-
tory force, and breathing pattern analysis.
Children, 5 years or older, can usually cooperate
and have enough muscle strength to perform the ma-
neuvers required for routine spirometry. Essential
components of routine spirometry are: forced vital ca-
pacity (FVC), forced expiratory volume in 1 second
(FEV^), and maximum forced expiratory flow (FEF^_^^).
At Arkansas Children's Hospital, pulmonary func-
tion testing is performed by registered technologists
who specialize in pediatric testing techniques. Expla-
nation of tests, demonstration, and practice maneu-
vers can improve performance in children with chronic
muscle weakness disorders. Spirometry can be per-
formed sitting or standing without effect on results.
Care should be taken in maintaining the trunk in an
upright position with the head erect and nose clips in
place.®
A slow vital capacity maneuver may be easier to
perform for children with advanced thorax and abdo-
men muscle weakness. This maneuver will not pro-
vide flow characteristics of the airways but is very ef-
ficient in providing definition of the primarily restric-
tive lung dysfunction of the Duchenne-type muscular
dystrophies.
Measurement of negative inspiratory force using a
simple pressure manometer can provide objective in-
formation regarding the strength of the child's cough
effort. This measurement is a valuable tool when evalu-
ating children unable to perform the FVC maneuver.
A history of sleep disturbances may warrant an
overnight pulse oximetry study and capillary blood
gas. These evaluations will determine the frequency
and duration of oxygen desaturations and concomi-
tant hypercapnias evidenced by elevated bicarbonate.
This information can assist in planning when to ini-
tiate mechanical hyperinflation therapy.
Respiratory Therapy: Treatments and
Techniques
Exercises for Breathing Muscles
In the early stages of Duchenne-type muscular
dystrophy, incentive breathing exercises can maintain
or improve respiratory muscle strength for an unde-
termined amount of time.’ An incentive spirometer is
used for these exercises. The device provides a vol-
ume goal for a deep breath and the child is encour-
aged to hold that volume for 10 to 15 seconds. Fifteen
to twenty deep breaths are encouraged four to six times
a day.
Aerosol Therapy
Aerosol therapy is a method of delivering medica-
tions directly into the lungs, avoiding systemic side
effects of oral medications. Specific medications in-
clude: mucolytics such as n-acetylcysteine or rhDNase,
decongestants such as neosynephrine, antibiotics, and
bronchodilators such as albuterol. A small air com-
pressor is attached to a hand-held nebulizer for aero-
sol generation. The child breathes slowly and deeply
through the nebulizer for 15 to 20 minutes 3 to 4 times
a day. Another method of delivering medication di-
rectly into the lungs is a metered dose inhaler (MDI).
An aerosol treatment program is designed to meet
the particular needs of the child during an acute respi-
ratory illness or in a long-term treatment plan. The
Pulmonary Medicine team at the MDA Clinic at Ar-
kansas Children's Hospital assists parents in equip-
Volume 93, Number 7 - December 1996
335
merit procurement and administration of aerosol
therapy.
Chest Physical Therapy
Chest percussion and gravity drainage is a method
of chest physical therapy used to loosen and mobilize
mucus in the airways. Clapping on the chest over cer-
tain areas of the lung will loosen mucus from the air-
way walls. Inclining the body in certain positions will
encourage gravity drainage of mucus. Deep breathing
and coughing is required during and after chest physi-
cal therapy. This form of therapy can be very effective
in removing mucus which has accumulated in the lung
during an acute respiratory illness.’” The Pulmonary
Medicine team assists parents in learning this form of
respiratory therapy.
Mechanical Ventilatory Aids
The primary focus of respiratory therapy applied
to children with Duchenne-type muscular dystrophy
is to assist in reducing the rate of decline of the vital
capacity. This is accomplished in stages over the pro-
gression of the disease with different methods of me-
chanical ventilatory assistance. Forms of mechanical
ventilatory assistance that are available today to chil-
dren with chronic muscle weakness disorders include:
1. Intermittant positive pressure breathing (IPPB).
IPPB is used for 15 to 20 minutes 2 to 4 times a day.
This small machine requires a mouthpiece for the con-
nection to the airway. Occasionally a nasal mask or a
face mask is used when facial muscles are weak. This
machine is very portable. This method of hyperinfla-
tion therapy should be introduced early in the course
of the disease, when the vital capacity drops below
60% of predicted.
2. A volume ventilator is used at night during sleep-
ing hours. This machine is slightly larger than an IPPB
machine and initially requires a nasal or face mask for
connection to the airway. The masks are comfortable
plastic with head and chin velcro straps to hold it in
place during sleep. This method of mechanical assis-
tance is introduced when the child is hypoventilating
when asleep, as evidenced by history and physical exam-
ination, pulse oximetry study, and capillary blood gas.
3. A volume ventilator can also be used during
the day as more assistance is needed during waking
hours. A mouthpiece or custom fabricated oral-nasal
interface can be used for daytime ventilator use. The
machine can easily fit on a ventilator tray on the bot-
tom of a powered wheelchair, allowing full and inde-
pendent mobility for the user.
When a volume ventilator is used during the day,
alternate approaches to airway connection can be con-
sidered. Wearing the plastic nasal or face mask during
the day may interfere with attending school, social
contact with family and friends, and may cause skin
irritation due to constant skin pressure. A mouthpiece
may not be tolerated due to weakened facial muscles,
336
air leakage, or dentation. The most commonly consid-
ered alternate approach for airway connection is a
tracheostomy. This allows the face to be free of
incumbrances and permits an easy connection to the
ventilator. A tracheostomy does not interfere with
speaking when a special valve (Passy-Muir) is in place.
Advantages of a tracheostomy include: small airway
connection, provides for removal of secretions with a
suction device reducing risk for mucus plugging and
infection, and allows aerosolized medications to be
delivered directly into the lungs.
A tracheostomy requires careful attention to hy-
giene for infection prevention. Caregivers are in-
structed in sterile techniques for suctioning. Because
the nose is bypassed, most patients require some hu-
midification.
Prevention of Pulmonary Complications
The frequency and severity of atelectasis and pneu-
monia in children with chronic muscle weakness dis-
orders is directly related to the degree of adherence to
an aggressive respiratory care plan. Anticipation and
prevention of lung complications through family and
patient education can improve the quality of life, pro-
mote health, delay the onset of pulmonary dysfunc-
tion, and enhance compliance with physician- recom-
mended respiratory care regimens.
The pulmonary medicine team at the MDA Clinic
at Arkansas Children's Hospital provides comprehen-
sive pulmonary evaluations for children diagnosed with
degenerative muscle disorders. This should be accom-
plished as soon as possible after the diagnosis has been
made. The frequency of subsequent clinic visits is
based upon the type of muscle disorder, history, physi-
cal examination, rate of decline of the vital capacity,
and complexity of their respiratory therapy regimen.
Obesity should be avoided in these children be-
cause of the further restriction this condition imposes
on ventilation. For the benefit of caregivers and pa-
tient, we obtain a formal nutrition consult from a pe-
diatric nutritionist. Immunizations should be up to date
and appropriate flu and bacterial vaccinations are en-
couraged annually.
Excessive muscle fatigue should be avoided, but
as much activity as tolerated without pain or fatigue is
encouraged. Cough suppressants and sedatives should
be avoided because of their interference with mucus
clearance. Avoidance of active or passive tobacco smoke
or other environmental irritants should be encouraged.
Early attention to upper respiratory infection (URI)
should be emphasized to caregivers. Information re-
garding the signs of URI including nasal stuffiness,
nasal drainage, low grade fever, and diminished ap-
petite are outlined in the Respiratory Care Handbook
and reviewed at clinic visits. Early treatments for a
URI include increased fluid intake, administration of
medication for fever control and pseudoephedrine for
reduction in nasal symptoms are also outlined in the
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Pulmonary Monitoring and Treatment Plan
The forced vital capacity (FVC) will be used to drive this care plan and
management will be determined based on changes in FVC. Introduce aerosol
and chest physical therapy for acute upper or lower respiratory tract infec-
tions as symptoms indicate at any point in the plan.
At the time of MD diagnosis
^introduce respiratory care handbook
^Pulmonary Function Testing (PFT) annually
*watch spinal growth by physical examination
FVC <75% predicted to 61% predicted
*PFT 4x per year
^follow any spinal curve by physical/radiological exam
*instruct in deep breathing with incentive spirometer
FVC<60% predicted
*PFT 4x per year
^follow any spinal curve by physical/radiological exam
^introduce intermittant positive pressure breathing (IPPB) qid
^evaluate for spinal stabilization surgery
FVC<40% predicted
’^PFT 6x per year
^follow spinal curve by physical/radiological exam
’^chest x-ray PRN (atelectasis and/or pneumonias)
^capillary blood gas
^overnight pulse oximetry study
^introduce mechanical volume ventilation by mask during sleeping
hours as indicated
“^evaluate for spinal stabilization surgery
FVC<30% predicted’^’"
*PFT 6x per year
*chest x-ray PRN
^capillary blood gas
"^overnight pulse oximetry study
^increase mechanical volume ventilation to include day and
night assistance
^tracheostomy for airway connection may be considered
** lungs at high risk for infection and atelectasis
handbook.
We educate the family in
recognition of symptoms of
lower respiratory infection
including hoarseness, cough,
and high, spiking fevers.
Caregivers are encouraged to
always seek medical advise
from their primary care phy-
sician for any respiratory
symptoms.
Conclusion
The pulmonary medicine
team at the MDA Clinic at
Arkansas Children's Hospital
is dedicated to providing early
assessment and aggressive
management for children
with degenerative muscle dis-
orders. Careful physical ex-
amination, frequent pulmo-
nary function monitoring, re-
inforcing a healthy lifestyle,
and pro-active management
of lung and orthopedic com-
plications are keys to provid-
ing the longest possible life for
these children. Technology
aiding in mobility and self-
care, and allowing vocational,
educational, and recreational
pursuits are imperative in
providing the best quality of
life for a child with Duchenne-
type muscular dystrophy.
References
1. Bach JR, Alba AS. Rehabilita-
tion of the patient with paralytic/
restrictive pulmonary syn-
dromes, in Pulmonary Therapy
Rehabilitation - second edition, Hass F, Axen K, Pineda H.
eds., Williams and Wilkins, Baltimore, 1991, 339.
2. Lyager S, Steffensen B, Juhl B. Indicators of need for
mechanical ventilation in Duchenne muscular dystrophy and
spinal muscle atrophy. Chest 1995;108:779-785.
3. Mohr CH, Hill NS. Long term follow-up of nocturnal ven-
tilatory assistance in patients with respiratory failure due to
Duchenne-type muscular dystrophy. Chest 1990;97:91-96.
4. Baydur A. Respiratory muscle strength and control of ven-
tilation in patients with neuromuscular disease. Chest
1991;99:330-338.
5. Smith P, Calverley P, Edwards R, Evans G, Campbell E.
Practical problems in the respiratory care of patients with
muscular dystrophy. N Engl J Med 1987;316(19):1197-1205.
6. McDermott I, Bach JR, Parker C, Sorter S. Custom-fabri-
cated interfaces for intermittant positive pressure ventilation.
Int J Prosthodon 1989; 2(3):224-233.
7. Jenkins JG, Bohn D, Edmonds JF, Levison H, Barker GA.
Evaluation of pulmonary function in muscular dystrophy
patients requiring spinal surgery. Surg 1982;10(10):645-649.
8. Garner RM, Hankinson JL, Clausen JL. Standardization
of spirometry-1987 update. Am Rev Respir Dis 1987;136:1285-1298.
9. Wanke T, Toifln K, Merkle M, Fromanek D, Lahrmann H,
Zwick H. Inspiratory muscle training in patients with
Duchenne muscular dystrophy. Chest 1994;105:475-482.
10. Bach JR. Pulmonary rehabilitation considerations for
Duchenne muscular dystrophy: prolongation of life by res-
piratory muscle aids. Crit Rev Phys and Rehabil Med
1992;3(3):239-269.
Volume 93, Number 7 - December 1996
337
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Loss Prevention
Aggressive Mismanagement
J. Kelley Avery, M.DA
Case Report
A 60-year-old man with known hypertension gave
a history of occasional bouts of "pressure" in the chest
and shortness of breath associated with mild to mod-
erate exertion for the past two years. These episodes
had been worse the past two months. The pain that
brought the patient into the hospital was described as
mid-sternal, radiating to the shoulders, and associated
with some breathlessness and diaphoresis.
In the emergency room, the patient was found to
have a blood pressure of 160/90 mm Hg. The chest
and heart were normal to auscultation. The EKG
showed small Q waves in leads III and AVF with "atypi-
cal but nonspecific appearing ST segments." The
echocardiogram was reported out as "normal," as was
the chest x-ray. Routine laboratory values, including
electrolytes and serum glucose, were normal. The pa-
tient was admitted as a "rule out myocardial infarc-
tion." Admission blood pressure was 150/88 mm Hg.
The patient was symptom-free. Both a thallium scan
and an exercise tolerance test were ordered.
On the day of admission, while waiting for the
treadmill test, the patient complained of chest pain
radiating to both arms. The physician was called; he
ordered a STAT EKG and nitroglycerin (NTG)
sublingually. Before the NTG was given, the blood
pressure was 190/112 mm Hg. With almost immediate
relief of chest pain the blood pressure was recorded at
170/110 mm Hg.
The physician ordered that the treadmill test be
done, and his M.D. associate was to remain with the
patient until the test was completed. The EKG showed
the Q waves persisting in leads III and AVF, and the T
waves inverted in U4-5. As the exercise test proceeded,
at 6 MET an atrial bigeminy was observed. The tread-
mill test was interrupted, and the thallium scan was
* Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Co., Brentwood, TN. This
article appeared in the Journal of the Tennessee Medical Associa-
tion in December 1992. It is reprinted here with permission.
begun. Cardiac arrest occurred with documented ven-
tricular fibrillation. Prompt and aggressive CPR was
ineffective, and the patient died.
A lawsuit was filed, charging negligence in the
failure to diagnose the infarction and in being out of
an acceptable standard of care in ordering and pro-
ceeding with the treadmill test in the face of evidence
strongly suggestive of acute myocardial infarction. No
expert witness could be found to support the attend-
ing physician's conduct of this case. A six-figure settle-
ment was negotiated.
Loss Prevention Comments
Our attending physician in this case was an expe-
rienced specialist in a fine urban medical facility. Could
it be that he had become so accustomed to success in
the aggressive management of acute myocardial inf-
arction that he had lost the edge of urgency and
guarded expectation necessary to make appropriate
decisions in the assessment and treatment of this kind
of patient?
In retrospect, I am sure that the physician could
not believe he had ignored the many signs of instabil-
ity in this patient! Was he too tired to make a good
decision? Was he distracted by a too busy schedule?
Was he impaired by chemical dependency? What was
it that prevented this physician from the cautious
management of his patient, which could have had a
positive outcome? Whatever it really was will not ap-
pear on the chart. It was not to be found in the area of
competence, experience, or training.
It is not easy to remain alert and properly focused
constantly. It is, in fact, humanly impossible to do so.
How can we prevent this type of behavior in ourselves?
When we get tired, rest! When we become overly pre-
occupied, back away - go to a movie, take a walk, or
do whatever helps us to refocus with clarity on the
patient and his problem. Sometimes it can be a matter
of life or death.
Volume 93, Number 7 - December 1996
339
Cardiology Commentary and Update
Laura M. White, Pharm.D.*
Stephanie F. Gardner, Pharm.D.**
J. David Talley, M.D.***
Adverse Drug Reactions
Drug interactions and drug-related adverse reac-
tions are significant problems in healthcare. Reports
have shown that drug reactions make up 0.3% to 7%
of all hospital admissions, and that 15% of all hospi-
talized patients have adverse drug reactions during
their hospital stays.* In addition, a study of 315 eld-
erly patients admitted to an acute care hospital found
that 28.2% of admissions were drug related.^ Adverse
drug reactions were to blame for 16.8% of those ad-
missions.^ The Harvard Medical Practice Study II found
that drug complications were the most common single
type of adverse event. Table 1 lists the drug classes
which were found to be responsible for the adverse
events of 30,195 patients in their order of frequency.*’
The most common types of adverse events caused by
drugs are hematologic, central nervous system, and
allergic/cutaneous reactions.
There are many different causes of drug related
adverse reactions: drug delivery issues (route and rate
of administration, or preparation related), pharmaco-
dynamic drug interactions (indirect, synergistic, an-
tagonist, or additive effects), and pharmacokinetic drug
interactions (alterations in absorption, distribution,
metabolism, or elimination). In this report, we illus-
trate examples of these types of drug related problems
and the significant effects these reactions have on clini-
cal outcomes.
Adverse Effects Related to Drug Delivery
Drug related adverse effects can be caused by an
inappropriate route or rate of drug administration or
can be preparation related. The following patient re-
* Dr. White is a Cardiovascular Pharmacotherapy Fellow in the
Department of Pharmacy Practice, UAMS College of Pharmacy.
** Dr. Gardner is an Associate Professor in the Department of
Pharmacy Practice, UAMS College of Pharmacy.
*** Dr. Talley is Professor of Internal Medicine and Director, Divi-
sion of Cardiology at UAMS Medical Center.
340
port demonstrates an adverse reaction caused by a drug
delivery problem: inappropriate route of administra-
tion for intravenous drugs."*
Patient Presentation
A 62-year-old female presented to her local emergency
room with nausea, diaphoresis, and chest pain. Based on
these symptoms and electrocardiographic evidence of S-T
segment elevation in the anterior leads, the patient was di-
agnosed with an acute anterior myocardial infarction. In
addition to routine supportive therapy, the patient received
tissue plasminogen activator (t-PA, Genentech, Inc., South
San Francisco, CA) 15 mg rapid IV push, followed by a 50
mg IV infusion over 30 minutes and a 35 mg IV infusion
over 60 minutes through a peripheral TV catheter in the
right arm. She was transferred to a tertiary hospital for
further evaluation and stabilization.
Upon arrival, the patient became critically hypotensive;
and dopamine IV 10 mcgikglmin was administered through
a new IV catheter in her right arm. An intraaortic balloon
pump was placed, and the patient was taken to cardiac cath-
eterization lab. A percutaneous transluminal coronary
angioplasty (PTCA) was performed successfully on the left
anterior descending artery.
On hospital day two, the patient began to complain of
pain and swelling in her right arm. Because the right radial
artery pulse was not palpable, the orthopedic surgery service
was consulted to further evaluate the vascular integrity of
the patient's right arm. The Whiteside technique confirmed
the diagnosis of compartment syndrome.
Fasciotomies were performed on the upper right extrem-
ity, which included a carpel tunnel release. Direct visualiza-
tion revealed a small localized hematoma at the dopamine
injection site, indicating a metabolic response due to dopam-
ine extravasation. This is in contrast to a mechanical cause,
such as a large generalized hematoma secondary to a crush
injury that can commonly precipitate compartment syndrome.
Reperfusion of the right upper extremity was observed by
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table 1:
Drug Classes Most Frequently Associated
with Drug Related Adverse Events
Drug Class
Frequencv
Antibiotics
16.2%
Antitumor agents
15.5%
Anticoagulants
11.2%
Cardiovascular agents
8.5%
Anticonvulsants
8.1 %
Diabetic agents
5.5%
Antihypertensives
5.0%
Analgesics
3.5%
Antiasthmatics
2.8%
Sedatives/Hypnotics
2.3%
Antidepressants
0.9%
Antipsychotics
0.7%
Peptic ulcer agents
0.5%
Other
19.3%
Total
100.0%
From: Leape LL, Brennan TA,
Laird N, Lawthers AG,
Localio R, Barnes BA, et al.
The nature of adverse
events in hospitalized patients
: Results of the Harvard
Medical Practice Study
II. N Engl J Med
1991;324:377-384.
the end of the surgery. The patient remained in critical con-
dition throughout her 20 day hospitalization and was dis-
charged with palpable pulses in the right arm and no nerve
damage.^
The above patient report illustrates the adverse
effect of compartment syndrome, which is the increase
in pressure within a closed compartment that com-
promises blood circulation and may result in tissue
necrosis. Thrombolytic therapy has been shown to
precipitate such a reaction in the extremities after in-
traarterial injections, internal bleeding, fractures, burns,
and crush injuries. The precipitating factor of com-
partment syndrome in the illustrated case is believed
to be the inappropriate administration of dopamine.
Dopamine was infused into a small vein in the same
arm where t-PA was given a few hours previously.
Dopamine extravasation potentially led to the tissue
damage that induced the compartment syndrome.
The adverse reaction of compartment syndrome
could have been avoided if dopamine had been ad-
ministered in a large vein, such as through a central
venous line, to minimize the risk of extravasation into
the surrounding tissue. Also, the risks of bleeding
could have been minimized by establishing vascular
access in the contralateral extremity. This case pro-
vides evidence that appropriate administration of
medications can reduce hospitalization costs.
Pharmacodynamic Drug Interactions
Adverse events can occur as a result of a drug
interaction that alters the pharmacodynamics of a spe-
cific drug by the indirect, synergistic, antagonistic, or
additive effects of another drug.^ An example of an
additive pharmacodynamic drug interaction is the use
of an antihistamine and hypnotic drug, which results
in compounded sedative effects.
Pharmacodynamic interactions can occur not only
between therapeutic agents, but also with diagnostic
agents such as contrast media. An indirect pharmaco-
dynamic interaction is illustrated by the complication
of lactic acidosis associated with radiologic contrast
media and metformin (Glucophage®, Bristol-Myers
Squibb Company, Princeton, NJ), an oral biguanide
antihyperglycemic agent used in non-insulin depen-
dent diabetics.^
Radiologic contrast dye, frequently used in pyelo-
graphic and arteriographic studies, has been demon-
strated to induce acute renal failure.^ Metformin, in
the presence of acute renal failure, can cause lactic
acidosis. Therefore, metformin should be discontin-
ued 48 hours prior to and following radiologic studies
involving contrast media to minimize the risk of lactic
acidosis.^
Cases of the metformin-lV contrast dye induced
lactic acidosis have been reported in the literature.
Assan and colleagues reported six cases of lactic aci-
dosis.* Five of the six metformin patients had IV con-
trast dye induced acute renal failure which resulted in
the development of lactic acidosis.*
Bristol-Myers Squibb Company, manufacturer of
the drug Clucophage®, has included a black box warn-
ing in the package insert concerning lactic acidosis and
has contraindicated its use when patients undergo ra-
diologic studies involving IV contrast media.* Although
this example of a drug/contrast media interaction is
rare, pharmacodynamic drug interactions can result
in life-threatening consequences.
Pharmacokinetic Drug Interactions
A third type of adverse drug reactions can occur
as a result of pharmacokinetic drug interactions. These
interactions are caused by alterations in absorption,
distribution, metabolism, or elimination of a drug af-
ter the administration of another drug. A common
cause of pharmacokinetic drug interactions is the in-
hibition or induction of the cytochrome P450 enzymes.
These enzymes, found in the liver and small intes-
tines, are involved in human drug metabolism.’ Phar-
macokinetic drug interactions typically result in
changes in drug concentrations in the body, and usu-
ally lead to an altered biological response.’
One example of a significant pharmacokinetic drug
interaction is the concomitant administration of digoxin
and amiodarone. This common drug interaction has
Volume 93, Number 7 - December 1996
341
been classified as clinically significant, because the
combination results in dramatic elevations of serum
digoxin levels. Case reports of levels increasing 69% to
800% have been published, but most studies indicate
a 50% increase in serum digoxin levels. In addition,
this drug interaction may take several days to develop
and serum digoxin levels may continue to rise over a
period of weeks to months. Although the exact mecha-
nism of the pharmacokinetic drug interaction between
amiodarone and digoxin is not fully established, stud-
ies indicate that amiodarone inhibits the renal and/or
nonrenal clearance of digoxin. Amiodarone may also
decrease tissue binding sites and increase the oral
bioavailability of digoxin.
Because of the significant toxicities associated with
rising serum digoxin levels, an empiric 50% reduction
of the digoxin dose is advised if both drugs are used.
In addition to serum digoxin levels, signs and symp-
toms of digoxin toxicity should be closely monitored.^
Pharmacokinetic drug interactions, such as the example
given, can result in detrimental, and even lethal outcomes.
Conclusions
Drug-related adverse reactions and interactions can
have significant effects on patient outcomes and hos-
pitalization costs. Yet, there are many ways to avert
such negative consequences. Avoiding the examples
given, assessing high risk patients (patients with re-
nal or hepatic impairment, elderly patients, and pa-
tients taking multiple medications), and encouraging
the use of the same physician and pharmacy will help
to decrease the incidence of preventable adverse pa-
tient outcomes.
References
1. May JR. Adverse Drug Reactions and Interactions. In:
DiPiro JT, Talbert RL, Hayes PE, Yee GC, Matzke GR, Posey
LM, editors. Pharmacotherapy: A Pathophysiologic Ap-
proach. 2nd ed. Norwalk: Appleton & Lange, 1993:71-83.
2. Col N, Fanale JE, Kronholm P. The Role of Medication
Noncompliance and Adverse Drug Reactions in Hospital-
izations of the Elderly. Arch Intern Med 1990; 150:841 -845.
3. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio R,
Barnes BA, et al. The Nature of Adverse Events in Hospital-
ized Patients: Results of the Harvard Medical Practice Study
II. N Engl I Med 1991;324:377-384.
4. White LM, Smith E, Gruenwald JM, Gardner SF, Stage P,
Talley JD. Tissue Plasminogen Activator (t-PA) Induced Com-
partment Syndrome and Dopamine Infiltration-Is There A
Connection? J Invas Cardiol (in press).
5. Glucophage. Package Insert. Bristol-Myers Squibb Com-
pany. 1996.
6. Parfrey PS, Griffiths SM, Barrett BJ, Paul MD, Genge M,
Withers J. Contrast Material-Induced Renal Failure in Pa-
tients With Diabetes Mellitus, Renal Insufficiency, or Both.
N Engl J Med 1989;320:143-149.
7. Digoxin. American Hospital Formulary Service Drug In-
formation. McEvoy GK, Editor. 1996;1093.
8. Assan R, Heuclin C, Ganeval D, Bismuth C, George J,
Girard JR. Metformin-Induced Lactic Acidosis in the Pres-
ence of Acute Renal Failure. Diabetologia 1977;13:211-217.
9. Slaughter RL, Edwards DJ. Recent Advances: The Cyto-
chrome P450 Enzymes. Annals of Pharmacotherapy
1995;29:619-624.
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JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Comparing Over 300 Term Plans
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Information provided by the Arkansas Department of Health, Division of Epidemiology
Reportable Disease Update
To simplify communicable disease reporting and
to conform with recommendations of the Centers for
Disease Control and Prevention, the following changes
have been made to the list of reportable diseases in
the Rules and Regulations Pertaining to Communicable
Disease Control.
Thirteen diseases that seldom occur in Arkansas
have been removed from the reportable disease list.
These diseases are Amoebiasis, Coccidioidomycosis,
Guillain-Barre Syndrome, Leptospirosis, Q Fever, Re-
lapsing Fever, Reye Syndrome, Smallpox, Thrichinosis,
Typhus Fever, Granuloma Inguinale, Lymphogranu-
loma Venereum and Gonococcal Ophthalmia.
The category of diseases that required reporting
only when outbreaks occur has been deleted and the
following statement substituted: "Report any unusual
disease or disease outbreaks that may require public
health assistance."
When reporting Syphilis, if the patient is preg-
nant, please indicate the trimester of pregnancy.
Any HIV-infected woman who is pregnant must
be reported as soon as pregnancy is confirmed. A re-
port must be made each time the woman is pregnant.
Pregnancy must be reported even if the person has
been previously reported as HIV-infected. Trimester
of pregnancy at time of reporting should also be given.
Congenital syphilis is to be reported separately
from other syphilis patients.
Anyone with questions or wanting copies of the
reportable disease list may call the Arkansas Depart-
ment of Health, Division of Epidemiology, at (501)
661-2893 or (800) 482-5400 during normal business
hours. For assistance after hours or during weekends
or holidays, please call (800) 554-5738.
Effects of Exposure to Toxic Substances Educational Video Available
The Arkansas Department of Health, through
funding from the Agency for Toxic Substances and
Disease Registry (ATSDR), has developed an educa-
tional program for physicians, residents and/or nurses
titled, "Effects of Exposure to Toxic Substances." This
program was developed to inform physicians and other
health care providers about the National Priorities List
(NPL) sites, also known as Superfund sites, in Arkan-
sas. At this time, Arkansas has 12 Superfund sites in
various locations around the state. The presentation
also provides information on the chemicals located on
those sites and their properties, routes of exposure.
diagnostic tests, and health effects.
The program was developed in two formats, video
tape and slide/audio. Both formats of the program are
available for viewing either from your local AHEC li-
brary or from the Arkansas Department of Health's
Resource Library. To check out the program from ADH,
please call our Resource Library at (501) 661-2572 or
call (501) 661-2604.
We hope that you will take advantage of the op-
portunity to access this resource which was developed
to assist physicians in learning more about one of the
environmental issues which is relevant to Arkansans.
344
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reported Cases of Selected Diseases in Arkansas
ProfQe for September 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
Sept. 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1994
Campylobacteriosis
29
193
116
153
140
187
Giardiasis
20
119
93
131
82
126
Shigellosis
18
105
93
176
139
193
Salmonellosis
78
361
248
332
432
534
Hepatitis A
31
376
476
663
190
253
Hepatitis B
5
62
62
83
41
60
HIB
0
0
5
6
3
5
Meningococcal Infections
2
27
27
39
41
55
Viral Meningitis
3
28
30
31
57
62
Lyme Disease
0
21
9
11
15
15
Rocky Mountain Spotted Fever
2
18
31
31
18
18
Tularemia
2
18
20
22
20
23
Measles
0
0
2
2
1
5
Mumps
0
1
6
5
5
7
Gonorrhea
***
★ ★★
***
5437
***
7078
Syphilis
ickie
***
***
1017
1096
Legionellosis
0
1
6
5
10
16
Pertussis
2
8
57
59
32
33
Tuberculosis
16
142
159
271
197
264
Not available at time of printing.
Do the Write** Thing!
We're always looking for interesting and informative
articles for The Journal. If you have a topic that you
think would be of interest to your peers, please submit it
for consideration to:
Managing Editor
The Journal of the Arkansas Medical Society
P.O. Box 55088
Little Rock, AR 72215-5088
(501)224-8967 (800)542-1058
MEDICAL - PATIENT
TREATMENT COORDINATOR
IMMEDIATE OPENING - For M.D. or D.O.
Outpatient Physical Rehab Center in Jonesboro,
Arkansas. Full time or part time. No evenings or
weekends. Salary negotiable. Reply:
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Volume 93, Number 7 - December 1996
345
New Members
BOONEVILLE
Suguitan, Demetrio Banaglorioso, Jr., Family
Medicine. Medical Education, Quezon City, Philip-
pines, 1994. Internship/Residency, Monteflore Medi-
cal Center, 1994/1996.
CROSSETT
McGowan, Patrick Francis, General Surgery. Medi-
cal Education, National University of Ireland, 1975.
Internship, Regional University Hospital, Galway, Ire-
land, 1976. Residency, Oklahoma University Health
Sciences Center, 1990. Board certified.
EUDORA
El-Hayeck, Maroun Elie, Medical Oncology/He-
matology. Medical Education, St. Joseph's University,
Beirut, Lebanon, 1990. Internship/Residency, 1991/1993.
Fellowship, Columbia University, 1996. Board certified.
FAYETTEVILLE
Brown, Richard Earl, Jr., Ophthalmology. Medi-
cal Education, UAMS, 1983. Internship, University
Hospital, 1984. Residency, University of Missouri at
Kansas City Truman Medical Center/Eye Foundation
of Kansas City, 1987. Board certified.
FORT SMITH
Murray-Stephens, Andrea Jeanette, Obstetrics/
Gynecology. Medical Education, Morehouse School of
Medicine, Atlanta, Georgia, 1991. Internship, Kaiser
Permanente Medical Center, Oakland, Calif., 1992.
Residency, Harbor Hospital Center, Baltimore, Mary-
land, 1996.
HOPE
Arrington, James Curely, Obstetrics/Gynecology.
Medical Education, Abraham Lincoln School of Medi-
cine, Chicago, Illinois, 1980. Internship/Residency,
Cook City Hospital, Chicago, Illinois, 1981/1984.
HOT SPRINGS
Vogel, Eric David, Emergency Medicine. Medical
Education, Chicago College of Osteopathic Medicine,
Chicago, Illinois, 1987. Internship, Brooke Army Medi-
cal Center, Houston, Texas, 1988. Residency, Joint
Military Medical Command, San Antonio, Texas, 1991 .
Board certified.
LITTLE ROCK
Bruce, Thomas Allen, (Retired) Cardiovascular
Medicine. Medical Education, UAMS, 1955. Internship,
Duke Hospital, Durham, N.C., 1957. Residencies,
Bellevue Hospital, New York, N.Y., 1958; Parkland
Hospital, Dallas, Texas, 1960; and Hammersmith Hos-
pital, London, 1961. Board certified.
Carey, Martin J., Emergency Medicine. Medical
Education, Welsh National School of Medicine, Cardiff,
South Wales, United Kingdom, 1979. Internship, South
Glamorgan General Practice Vocational, Training
Scheme, Dept, of General Practice, Cardiff, South
Wales, 1984. Residency, Emergency Medicine Train-
ing Schreme, Middlemore Hospital, Auckland, 1991.
Coffman, John Lawrence, Anesthesiology. Medi-
cal Education, UAMS, 1992. Internship/Residency,
UAMS, 1993/1996.
Ford, Barry Graves, Family Practice. Medical Edu-
cation, UAMS, 1993. Internship, Chippenham Medi-
cal Center, Richmond, Virginia, 1994. Residency, Ches-
terfield Family Practice, Richmond, Virginia, 1996.
Board pending.
Hatch, Allan B., Cardiovascular Disease. Medical
Education, East Carolina University, Greenville, N.C.,
1989. Internship, Pitt County Memorial Hospital, 1990.
Residency, Howard University, 1992. Board certified.
Napolitano, Charles Augustine, Anesthesiology.
Medical Education, Bowman Gray School of Medicine,
Wake Forest University, Winston-Salem, N.C., 1990.
Internship, North Carolina Baptist Hospital, 1991. Resi-
dency, University of Florida College of Medicine, 1994.
Fellowship, University of Florida, 1996. Board eligible.
NORTH LITTLE ROCK
Cook, Jonathan Mitchell, Family Practice. Medi-
cal Education, West Virginia School of Osteopathic
Medicine, Lewisburg, W.V., 1993. Internship/Resi-
dency, UAMS, AHEC-Pine Bluff, 1994/1996. Board
certified.
PINE BLUFF
Lamb, Johnny M., (Retired) General Surgery.
Medical Education, UAMS, 1967. Internship, Keesler
Air Force Base, Mississippi, 1968. Residency, Emory
University, Atlanta, Georgia, 1975. Fellowship, Roswell
Park, Buffalo, N.Y., 1979. Board certified.
WALDRON
Ploetz, Carina, Family Medicine. Medical Educa-
tion, UMDNJ, Stratford, N.J., 1993. Internship/Resi-
dency, UMDNJ, 1994/1996. Board certified.
346
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
RESIDENTS
Fletcher, James William, III, Transitional. Medi-
cal Education, UAMS, 1996. Internship, UAMS.
Henry, Mary J., Radiology. Medical Education,
University of Tennessee, Memphis, 1994. Residency, UAMS.
Hester, Wes Lee, Family Practice. Medical Educa-
tion, UAMS, 1995. Internship/Residency, UAMS,
AHEC-Southwest, 1996/current.
Molette, Sekou F.M., Physical Medicine & Reha-
bilitation. Medical Education, Meharry Medical Col-
lege, Nashville, Tennessee, 1992. Internship, Mount
Sinai - Elmhurst Hospital Center, New York. Residency,
UAMS.
Rankin, Jay K., Psychiatry. Medical Education,
UAMS, 1995. Internship, Medical College of South
Carolina, Charleston. Residency, UAMS.
Rayford, Richard, Medicine/Cardiology. Medical
Education, University of Mississippi School of Medi-
cine, Jackson, 1991. Internship/Residency, University
of Tennessee, Memphis, 1992/1994. Fellowship, UAMS.
Shihabuddin, Bashir Sami, Internal Medicine/
Neurology. Medical Education, American University
of Beirut, Lebanon, 1993. Internship, Good Samaritan
Hospital of Maryland, Baltimore, 1994. Residency,
UAMS.
STUDENTS
Kimberly D. Baber
Daniel J. Harris
John Eric Henriksen
Kristin Diane Kaemmerling
Michelle Lynn LaCroix
Bruce W. Lewis
Ronald Brian Owens
Dennis Wayne Ozment
Richard D. Schmidt
Jennifer Trew Scruggs
Jeri Kersten Mendelson
Camille Hall Swihart
BE AN AIR FORCE
PHYSICIAN.
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want to be while serving your country in
today’s Air Force. Discover the tremen-
dous benefits of Air Force medicine. Talk
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• Non-contributing retirement plan if
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Volume 93, Number 7 - December 1996
347
In Memoriam
Guy R. Farris, M.D.
Dr. Guy R. Farris, of Little Rock, died Sunday, October 27, 1996. He
was 76. His family includes his wife, Joan; a brother, William J. "Bill"
Farris of Enola; two sons, Guy Raymond Farris III of Tucson, Arizona,
and Richard E. Farris of Little Rock; two daughters, Ruth Ann Yancey
of Colorado Springs, Colorado, and Kristi Broglen of Little Rock; 11
grandchildren; and three great-grandchildren.
348
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
Steven R. Nokes, M.D., Editor
Authors
Steven R. Nokes, M.D.
Charles P. Fitzgerald, M.D.
CD. Williams, M.D.
History:
A 58-year-old man presented with dyspnea. The patient had undergone triple coronary artery bypass grafting
several years earlier. A chest film (figure 1), echocardiogram, and CT scan of the chest (figures 2 a-c), were per-
formed.
Figure 1 Figure 2a
Figure 2c
Figure 1 : PA Chest x-ray.
Figure 2: CT scans of the chest at the level of the heart (a, b) and sagittal reconstruction (c).
Figure 2b
Volume 93, Number 7 - December 1996
349
Right Coronary Artery Bypass Graft Aneurysm
Diagnosis: Right coronary artery bypass graft aneurysm.
Findings:
The chest film reveals a subtle extra density adjacent to the right heart border. The CT scan demonstrates a 7
cm mass indenting the right atrium with central contrast enhancement and peripheral decreased attenuation. The
sagittal reconstruction identified a contrast connection from the right coronary graft to the center of the mass. A small
right pleural effusion is present.
Discussion:
Aneurysms of aortocoronary saphenous vein bypass grafts are rare, and can occur as early or late complica-
tions. Most occur at an anastomotic site. The mechanism by which these aneurysms develop is unclear and prob-
ably multifactorial. Complications include distal thromboembolism, myocardial infarction and rupture.
Previously the diagnosis rested on coronary angiography. With the advent of faster CT scanners (helical and
electron beam) images can be obtained during the arterial phase when the lumen is identifiable. Angiography re-
mains necessary for preoperative planning. Scans obtained with older scanners typically revealed an anterior medi-
astinal mass suggesting teratoma, thymoma, lymphoma, or a pericardial cyst.
References:
1 . Forster DA, Haupert MS. Large mediastinal mass secondary to an aortocoronary saphenous vein bypass graft aneurysm.
Ann Thorac Surg 1991 ; 52:547-8.
2. Yousen D, Scott W, Fishman EK, Watson AJ, Traill T, Gimenez L. Saphenous vein graft aneurysms demonstrated by com-
puted tomography. J Comput Assist Tomogr 1986; 10:526-8.
3. Vijayanager R, Shafii E, DeSantis M, Waters RS, Desai A. Surgical treatment of coronary aneurysms with and without
rupture. J Thorac Cardioasc Surg 1994; 107:1532-5.
Editor and Author: Steven R. Nokes, M.D. is associated with Radiology Consultants in Little Rock.
Author: Charles P. Fitzgerald M.D. is associated with Arkansas Heart Group in Little Rock.
Author: C. D. Williams is associated with Arkansas Cardiovascular Surgery Associates, P.A. in Little Rock.
350
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Things To Come
January 17-19, 1997
Essentials of Prostate & Genitourinary Imaging.
Marriott's Orlando World Center Resort, Orlando,
Florida. Jointly sponsored by the Foundation for Health
Education and Medical Education Collaborative. Eor
more information, call (908) 636-1256 or 1-800-599-8878.
February 8-10, 1997
12th Annual Mardi Gras Anesthesia Update in
New Orleans. Westin Canal Place Hotel, New Orleans,
Louisiana. Sponsored by the Department of Anesthe-
siology & Center for Continuing Medical Education,
Tulane University Medical Center. For more informa-
tion, call (504) 588-5466 or 1-800-588-5300.
February 9-14, 1997
Advances in Imaging; 1997. Manor Vail Lodge,
Vail, Colorado. Sponsored by the Departments of Ra-
diology at Tulane University Medical Center and Loui-
siana State University School of Medicine. For more
information, call (504) 588-5466 or 1-800-588-5300.
February 20-23, 1997
Current Issues in Gynecologic Endoscopy. The
Resort at Squaw Creek, Squaw Valley, California. Spon-
sored by the American Association of Gynecologic
Laparoscopists. For more information, call (310) 946-
8774 or 1-800-554-2245.
February 26-28, 1997
The Third National Primary Care Conference:
Community-Based Academic Partnerships. Washing-
ton Sheraton Hotel, Washington, DC. Sponsored by
Health Resources & Services Administration, U.S. De-
partment of Health & Human Services. For more in-
formation, call (301) 986-4870.
March 7-9, 1997
Management of the HIV-Infected Patient; A Prac-
tical Approach for the Primary Care Practitioner.
Crowne Plaza Manhattan, New York City. Sponsored
by the Center for Bio-Medical Communication, Inc.,
in collaboration with the American Foundation for AIDS
Research. For more information, call (201) 385-8080.
March 21-25, 1997
North American Skull Base Society 8th Annual
Meeting Combined with 2nd International Congress
on the Cerebral Venous System 2nd International
Congress on Meningiomas. The Excelsior Hotel, Little
Rock, Arkansas. For more information, call (301) 654-6802.
April 4-5, 1997
Clinical Pulmonary Update. Washington Univer-
sity Medical Center, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. Eor more infor-
mation, call 1-800-325-9862.
April 10-12, 1997
Refresher Course & Update in General Surgery.
The Ritz-Carlton Hotel, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 25-27, 1997
1997 Pediatric Update for the Primary Care Phy-
sician. The Westin Canal Place, New Orleans, Louisi-
ana. Co-sponsored by the Alton Ochsner Medical Foun-
dation and Tulane University School of Medicine. For
more information, call (504) 842-3702 or 1-800-778-9353.
September 5-7, 1997
4th Annual Current Topics in Cardiothoracic
Anesthesia. Washington University Medical Center,
St. Louis, Missouri. Sponsored by the Office of Con-
tinuing Medical Education, Washington University
School of Medicine. For more information, call 1-800-
325-9862.
September 18-20, 1997
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
Volume 93, Number 7 - December 1996
351
Keeping Up
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category 1 of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General hiternal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon, Southwestern Bell/Arkla Room. Lunch provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Anesthesiology Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Breast Conference, 3rd Thursday, 7:00 a.m.. Conference Room 1
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pathology Conference, 1st Tuesday, 3:00 p.m.. Pathology Library
Pediatric Grand Rounds, Tuesdays, 12:00 noon. Especially for Women Resource Room, 2nd floor/BMC. Category 1 credit
available. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
NORTH LITTLE ROCK-BAPTIST MEMORIAL HOSPITAL
Chest & Problems Case Conference, 3rd Wednesday, 12:00 noon. Assembly room. Lunch provided.
Grand Rounds, 1st Monday (3rd, chest), 12:00 noon. Assembly room.
The University of Arkansas College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor
the following continuing medical education activities for physicians. The Office of Continuing Medical Education designates that these
activities meet the criteria for credit hours in category 1 toward the AM A Physician's Recognition Award. Each physician should claim only
those hours of credit that he/she actually spent in the educational activity.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Taculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education 111 Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
352
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTl/ Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
Gl/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Fetal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education 11 Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology/ Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
Volume 93, Number 7 - December 1996
353
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teachmg Coiiferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spme Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical CenterJONESBORO-AHEC NORTHEAST
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital GME Gonference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Gonference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Internal Medicine Gonference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/ Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner'Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
354
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Volume 93, Number 7 - December 1996
355
Arkansas Medical Society Membership Roster
as of November 12, 1996 # Denotes deceased member
Arkansas County
Burleson, Stan W.
Chavin, Michael A.
Daniel, Noble B. Ill
Hestir, John M.
Millar, Paul H. Jr.
Morgan, Jerry D.
Northeutt, Carl E.
Pritchard, Jack L.
Speer, Hoy B. Jr.
Speer, Marolyn N.
Tracy, W. Lee
Yelvington, Dennis B.
Ashley County
Burt, Frederick N.
Garcia, Luis F.
Gresham, Edward A.
Heder, Guy W.
Henry, William Jr.
McGowan, Patrick F.
Rankin, James D.
Salb, Robert L.
Spohn, Peter J.
Thompson, Barry V.
Toon, D. L.
Walsh, Benjamin J.
Baxter County
Adkins, Kevin J.
Baker, Robert L.
Barker, Monty
Barnes, Gregory
Beck, Dennis
Chatman, Ira D.
Cheney, Maxwell G.
Ghock, Daniel P.
Chock, Helga E.
Clarke, James S.
Condrey, Yoland M.
DeYoung, Bruce
Douglas, Donald S.
Dyer, William
Dykstra, Peter C.
Elders, John Gregory
Foster, Robert D.
Guenthner, John F. #
Hagaman, Michael S.
Hardin, Philip R.
Johnson, Stacey M.
Kelley, Lawrence A.
Kerr, Robert L.
Kilgore, Kenneth M.
Knox, Thomas E.
Landrum, William
MacKercher, Peter A.
Massey, James Y.
McAlister, Matthew
McBride, Anthony D.
Neis, Paul R.
Price, Michael D.
Pritchard, Jamie
Regnier, George G.
Rigler, Wilson F.
Robbins, Bruce
Roberts, David H.
Saltzman, Ben N.
Short, Luke H.
Simons, Roger D.
Sneed, John W. Jr.
Stahl, Ray E. Jr.
Sward, David T.
TerKeurst, John
Trager, Marc
Tullis, Joe M.
Turner, Frederick C.
Wells, Gary
White, Edward
White, Richard B.
Wilbur, Paul F.
Wilson, Jack C.
Yoder, Robert Raymond
Benton County
Addington, Alfred R.
Alderson, Roger
Allen, L. Barry
Allen, William M.
Arkins, James
Atkinson, Thomas
Ball, Eugene H.
Becton, Paul Jr.
Benjamin, George
Benson, Stuart
Black, Randall Wayne
Bledsoe, James H.
Boden, Donna
Boozman, Fay W. Ill
Cantwell, Janet
Clemens, R. Dale
Clower, John D.
Cohagan, Donald L.
Cole, Randall E.
Compton, Neil E.
Costaldi, Mario E.
Cuchia, John
Dang, Minh-Tam
Day, Geoffrey
Deatherage, Joseph R.
Denman, David A.
Diacon, W. Lindley
Donnell, Hugh Garland
Donnell, Robert W.
Elkins, James P.
Ewart, David
Fioravanti, Bernard L.
Friesen, Douglas L.
Garrett, David C. Ill
Goss, Stephen
Halinski, David
Harmon, Harry M.
Heiss, Nancy
Henderson, Oscar L.
Hitt, Jerry L.
Hof, C. William
Holder, Robert E.
Horner, Glennon A.
Howard, K. Lamar
Hull, Robert R.
Huskins, James D.
Huskins, John A.
Jacks, John W.
Jennings, William E.
Johnson, Ghristopher S.
Johnson, Royce Oliver II
Johnson, Steven P.
Keane, Patrick K.
Knapp, James R.
Lanier, Karen A.
Lewis, Rebecca G.
Marciniak, Douglas L.
McGollum, Edward
McGollum, William
McKnight, William D.
Mertz, John Douglas
Mishkin, David
Moose, John I.
Mullins, Neil D.
Neaville, Gary A.
Nugent, Loyd
Panettiere, Frank J.
Pappas, John J.
Pearson, Richard N.
Pickens, James L.
Platt, Michael R.
Poemoceah, Kenneth M.
Puckett, Billy J.
Reese, Michael C.
Revard, Ronald
Ritz, Ralph C.
Rollow, John A.
Rolniak, Wallace A.
Springer, Dan J.
Steadman, Hunter M. Jr.
Stinnett, Gharles H.
Stinnett, Scott G.
Stolzy, Sandra
Summerlin, William
Swaim, Terry J.
Swindell, William G.
Tate, Jeffrey
Treptow, Douglas
Turley, Jan T.
Warren, Grier D.
Weaver, Robert H.
Webb, William
Wright, Larry D.
Youngblood, Thomas
Boone County
Abdelaal, Ali F.
Ashe, Barbara
Baumwell, Sterling H.
Bell, Thomas Edward
Bennett, Ghris
Bennett, Joe D.
Brand, Robert
Brandon, Henry
Casey, Rick E.
Chambers, Carlton L. Ill
Chambers, Sue
Chu, Victor
356
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Collins, Kenneth
Crider, James T.
Daniel, Charles D.
Dunaway, Geoffrey
Ferguson, Noel F.
Flanigan, Stevenson
Fowler, Ross E.
Helmling, Robert L.
Hope, John M.
Kim, Hyewon
Klepper, Charles R.
Langston, James David
Langston, Robert H.
Langston, Thomas
Ledbetter, Charles A.
Leslie, Sharron J.
Leslie, Thomas S.
Maes, Stephen R.
Mahoney, Paul L. Jr.
Maris, Mahlon O.
Mears, Bill
Miller, Robert Jr.
Morris, Robert II
Padilla, Jose S. Jr.
Reese, Ronald R.
Rozeboom, Victor A.
Scroggie, Daniel J.
Scroggins, Sam J.
Shapter, Janet B.
Van Ore, Stevan Michael
Vowell, Don R.
Welch, William P.
Williams, Rhys A.
Bradley County
Chambers, F. David
Coyle, Pamela
Fort, David Jr.
Foscue, David
Marsh, James W.
Pennington, Kerry F.
Wharton, Joe H.
Wynne, George F.
Carroll County
Card, Shannon R.
Flake, William K.
Horton, Charles
Kresse, Gregory
Martinson, Alice
McAlister, Robin
Nash, John R.
Spann, Eric G.
Spurgin, Randal Truman
Stensby, Harold E.
Taylor, Richard L.
Wallace, Oliver
Warner, Milo N.
Chicot County
Burge, John P.
Kronfol, Ned
Mansour, George
Russell, John R.
Smith, Major E.
Thomas, H. W.
Tuangsithtanon, T.
Tvedten, Tom
Weaver, William J.
Wilson, Thomas C.
Clark County
Anderson, P. R.
Balay, John W.
Bryan, Yvon P.
Dorman, Robert A.
Elkins, John S.
Eerrari, Victor J. Jr.
Eord, Michael Ray
Fullerton, John C. Ill
Hagood, Noland Jr.
Jansen, Mark
Kluck, Carl Jr.
Lowry, James L.
McLeod, Kevin
Peeples, George R.
Taylor, George D.
Teed, Frank S.
Cleburne County
Baldridge, Max
Barnett, James C. #
Barnett, Michael
Beasley, Harold
Bivins, Franklin Jr.
Quinn, Cynthia D.
Sharp, Jan
Thomas, Jerry L.
Vaughan, G. Lee
Columbia County
Alexander, John E. Sr.
Alexander, John E. Jr.
Baldwin, Ronald L.
Evans, Matthew L.
Farmer, John M.
Griffin, Rodney L.
Hester, Joe D.
Hunter, Robert W. Jr.
Kelley, Charles W.
McMahen, H. Scott
Murphy, Fred Y.
Parkman, Robert L. Jr.
Pullig, Thomas A.
Roberts, Franklin D.
Ruff, John L.
Strange, Vance M. #
Walker, Jack T.
Wynn, Chester
Conway County
Duensing, Theodore
Hickey, Thomas H.
Lipsmeyer, Keith M.
Owens, Gastor B.
Wells, Charles F.
Craighead-Poinsett
County
Allen, John M.
Alston, Herman D.
Ameika, James A.
Aston, J. Kenneth
Awar, Ziad
Ball, John
Barker, Charles
Basinger, James W.
Beck, M. Lowery
Berry, Donald M.
Berry, Michael P.
Blachly, Ronald J.
Blaylock, Jerry D.
Bolt, Michael E.
Boyd, John T.
Braden, Terence P. Ill
Brown, Dennis R.
Brown, Mark C.
Burns, Richard G.
Burns, Robert
Bush, Anne E.
Camp, Michael
Carpenter, Kennan
Casanova, Robert Jr.
Chan, Kenneth
Chediak, Gregory
Clopton, Owen H. Jr.
Cohen, Evan Scott
Cohen, Jeffrey O.
Cohen, Robert S.
Collins, Kevin Basil
Cook, John
Cranfill, Ben
Cranfill, General L. Ill
Crawley, Michael E.
Deem, Brent S.
Degges, Russell D.
Dickson, Glenn E.
Dow, J. Timothy
Duke, Billy L. II
Dunn, Charles C.
Eddington, William R.
Edwards, Carl B.
Emerson, Steven
Felts, Larry S.
Fields, L. Brad
Foote, John W.
Forestiere, A. J.
Garner, B. Matt
Garner, William L.
George, F. Joseph
Golden, Stephen C.
Gossett, Clarence E.
Goza, Gary R.
Green, Terri
Green, William Robert
Guinn, Donald R.
Hackbarth, Mark A.
Hall, Ray H. Jr.
Harvey, Bryan
Hiers, Connie L.
Hightower, Michael D.
Hill, Roger D.
Hogue, Ernest L.
Hoke, W. Scott
Houchin, Vonda
Hubbard, William S.
Hurst, William
Isaacson, Michael L.
James, Erank M.
Jennings, R. Duke
Jiu, John B.
Johnson, John A.
Johnson, Larry H.
Johnson, Roehl W.
Jones, K. Bruce
Jones, R. J.
Keisker, Henry W.
Kemp, Charles E.
Kostick, Richard A.
Kroe, Donald J.
Kyle, Richard
Volume 93, Number 7 - December 1996
357
Labor, Penny M.
Labor, Phillips K.
Landry, Robert J.
Lawrence, Robert O. Jr.
Ledbetter, Joseph W.
Lepore, Diane G.
Levinson, Mark
Lewis, David M.
Lunde, Stephen P.
Luter, Dennis W.
Lynch, John
Mackey, Michael
Maglothin, Douglas L.
Mahon, Larry E.
Marzewski, David
McDaniel, Craig A.
McKee, Sanders
Modelevsky, Aaron C.
Montgomery, Earl W.
Moseley, Claiborne II
Murrey, James F.
Nash, Jerry
Nixon, D. Allen Jr.
Owen, Kip
Owens, Ben Jr.
Parten, Dennis
Patel, Dharmendra V.
Peacock, Loverd
Porter, Revel D.
Price, Edwin F.
Price, Herbert H. Ill
Pryor, Shapard Jr.
Pyle, David
Ragland, Darrell G.
Rainwater, W. T.
Rauls, Stephen R.
Ricca, Dallie
Ricca, Gregory F.
Richards, Fraser M.
Roberts, Randy D.
Rogers, James F.
Rusher, Albert H. Jr.
Sales, Joseph Hugh
Sanders, James W.
Sapiro, Gary S.
Sauer, Curtis
Savage, Patrick Joseph
Schrantz, James L.
Scriber, Ladd J.
Scroggin, Carroll D. Jr.
Shanlever, William T.
Sifford, Mark
Silas, David
Skaug, Phyllis
Skaug, Warren A.
Smith, Floyd A. Jr.
Smith, Michael J.
Smith, Vestal B.
Sneed, Jane
Snodgrass, Scot J.
Sparks, Barrett
Spencer, John P.
St Clair, John T. Jr.
Stainton, Joseph C.
Stainton, Robert M. Jr.
Stallings, Joe H. Jr.
Stank, Thomas M.
Stevenson, Richard
Stidman, Jeff
Stripling, Mark C.
Stroope, Henry F.
Stubblefield, Sandra
Stubblefield, William
Swingle, Charles G.
Tagupa, Eumar
Taylor, Robert D.
Tedder, Barry C.
Tedder, Michael E.
Templeton, Gary L.
Thomas, Gary A.
Tidwell, Kenneth Jr.
Tonymon, Kenneth
Tuck, Rebecca
Verser, Michael
Vines, Troy Alan
Vollman, Don B. Jr.
Walker, Meredith M.
Warner, Robert L. Jr.
White, Anthony T.
Wiggins, H. Lynn
Williams, Anthony
Williams, E. Walden
Wilson, Joe T. Jr.
Wisdom, Garland Durwood
Woloszyn, John
Wood, Mark Cole
Woodruff, Stephen O.
Woodward, Gary W.
Yates, Robert L.
Young, William C. Jr.
Crawford County
Concepcion, Cecilia L.
Darden, Lester R.
de Mondesert, Eduardo A.
Delk, John II
Doyle, Edward
Edds, Millard C.
Edwards, Henry N.
Flanagan, Mary Clare
Floyd, Rebecca R.
Hazar, Derya B.
Heaver, Holly M.
Hefner, David P.
Jennings, Charles A.
Katz, Catherine
Mason, Joe N.
Ross, R. Wendell
Sasser, L. Gordon III
Schlabach, Ronald D.
Sills, D. Bart
Travis, A. Lawrence
Crittenden County
Adler, Justin Jr.
Arnold, Sidney W.
Barr, Marian
Bryant, G. Edward Jr.
Clemons, Mark
DeRossitt, James P. Ill
Deneke, Milton D.
Evans, Loraine J.
Ferguson, Scott
Ferguson, T. Murray
Ford, Robert C. Jr.
Greene, Robert W. Jr.
Hernandez, Jacinto
Huffstutter, Paul J.
Kaplan, Bertram
Kennedy, Keith B.
L'Heureux, Guy J.
Meredith, Samuel G. Jr.
Miller, James L.
Murray, Ian F.
Nadeau, Kenneth R.
Peeples, Chester W. Jr.
Peeples, Guy Langley
Pierce, Trent P.
Rudorfer, Bennett Lewis
Ruiz, Julio P.
Schoettle, Glenn P. #
Schoettle, Steve P.
Shrader, Floyd R.
Smith, Bedford W.
Smith, Mark M.
Utley, L. Thomas
Wah, John
Webb, Dan W.
Westmoreland, Daniel
Wright, William J.
Cross County
Beaton, J. Trent
Beaton, Kenneth E.
Bethell, Robert D.
Burks, Willard G.
Crain, Vance J.
Hayes, Robert A. Jr.
Jacobs, James R.
Dallas County
Delamore, John H.
Howard, Don
Nutt, Hugh A.
Spears, Robert S.
Suphan, Neema A.
Desha County
Asemota, Steve
Go, Peter Kong Hua
Harris, Howard R.
Masquil, Filipe
Prosser, Robert L. Ill
Scott, Robert B.
Turney, Lonnie R.
Young, James E.
Drew County
Burns, Robert E.
Busby, Arlee K.
Gordon, Leonard F.
Maxwell, Ralph M.
McKiever, William R.
Wallick, Paul A.
Williams, William III
Wilson, Harold F.
Faulkner County
Arnold, Robert S.
Beasley, Margaret D.
Bell, F. Keith
Benafield, Robert B.
Bowlin, Randal
Bowman, Gary
Carter, D. Mike
Clark, Robert L. Jr.
Collins, Mitchell L.
Connaughton, Michael A.
Cummins, J. Craig
Daniel, Sam V.
Dixon, Jerry W.
358
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Dodge, Ben
Furlow, William C.
Garrison, James S.
Ghormley, J. Tod
Gordy, L. Fred Jr.
Gray, George T. Ill
Hendrickson, Richard O. Jr.
Hudson, Thomas F. Ill
Huggins, David P.
Jackson, Carole
Landberg, Karl H.
Lewis, Gregory
Magie, Jimmie J.
Martin, David A.
McCarron, Robert
McChristian, Paul L.
Murphy, Kenneth
Raney, Herschel D. Jr.
Roberts, Thomas
Ross, Rex W.
Shaw, Collie B.
Shirley, David C.
Smith, John D.
Smith, Lander A.
St. Amour, Scott C.
Stancil, Vicki
Stone, Phillip
Throneberry, Bart
Wright, Gary David
Franklin County
Brooks, Homer E.
Gibbons, David L.
Lachowsky, John
Long, C. C.
Smith, John C.
Wilson, Robert
Zabad, Hussein
Garland County
Arthur, James M.
Aspell, Robert
Atherton, Lee G.
Bandy, Preston R.
Bennett, Keith
Bodemann, Diane
Bodemann, Donald R.
Bodemann, Michael C.
Bodemann, Stephen L.
Bohnen, Loren O.
Boos, Donald Jr.
Borg, Robert V.
Borland, Judy
Bracken, Ronald J.
Braley, Richard E.
Braun, James R.
Brunner, John H.
Burton, Frank M.
Burton, James F.
Campbell, James W.
Cates, Jack A.
Cenac, Joseph W. Jr.
Cunningham, Mark
Cupp, Cecil W. Ill
Cyrus, Scott S.
Daniel, Robert G.
Davis, Kjristie L.
Davis, Sheryl L.
Dodson, John W. Jr.
Dolan, Patrick III
Dunn, Richard W.
Dykman, Kathryn
Eisele, W. Martin
English, P. Timothy
Finch, Richard R.
Fine, B.D. Jr.
Fore, Robert W.
Fotioo, George J.
French, James H.
Gammill, Todd
Gardial, J. Richard
Gardner, James L.
Gerber, Allen D.
Gocio, Allan C.
Griffin, James E.
Haggard, John L.
Hale, Kevin D.
Harper, Edwin L.
Headrick, Daniel
Hechanova, D. M. Jr.
Heinemann, Fred M.
Heinemann, Phyllis E.
Henderson, Francis M.
Henson, Clinton H.
Hickman, Michael P.
Hill, Robert L.
Hitt, W. C. Jr.
Hollis, Thomas H.
Howe, H. Joe
Hughes, James A.
Hulsey, Matthew
Humphreys, Robert P.
Hunter, Karla
Irwin, William G.
Jackson, Brian D.
Jackson, Haynes G.
Jackson, Haynes G. Jr.
Jackson, Michael S.
James, Janeen
Jayaraman, K. K.
Jayaraman, Vilasini D.
Jayasundera, Naomal S.
Johnson, Robert D.
Johnston, Gaither C.
Josef, Stanley
Kaler, Ron A.
Keadle, William R.
Kincheloe, A. Dale
Kleinhenz, Robert W.
Klugh, Walter G. Jr.
Koehn, Martin A.
Lane, Charles S. Ill
Larey, Mark E.
Larrison, Charles A.
LeMay, Thomas B.
Lee, Allen R.
Lee, William R.
Lennon, Yates
Lyles, Fred
Martin, Jana
Maruthur, Gopakumar
Mashburn, William R.
Mathews, John S.
McCrary, Robert F. Jr.
McFarland, Louis R.
McMahan, James
Meek, Gary N.
Munos, Louis R.
Olive, Robert Jr.
Pai, Balakrishna
Pappas, Deno P.
Parkerson, Cecil W.
Peeples, Raymond E.
Pellegrino, Richard
Plaza, Jesus' A.
Powell, Brenda
Puen, Roy L.
Queen, George P.
Rainwater, W. Sloan
Rayburn, John
Reddy, Prabhakara K.
Robbins, Mark
Robert, Jon M.
Roda, Perdinand T.
Rosenzweig, Joseph L.
Russell, Mark
Sanders, Hallman E.
Seifert, Kenneth A.
Sharma, Bimlendra
Shelby, Eugene M.
Shroff, Rajesh K.
Simpson, John B.
Slaton, G. Don
Sloand, Timothy Peter
Smith, Bruce L. Jr.
Smith, John W.
Smith, Phillip L.
Sorrels, John W.
Sousan, Leo
Springer, Melvin R. Jr.
Springer, William Y.
Stecker, Elton H. Jr.
Stecker, Rheeta M.
Stough, D. Bluford III
Stough, Dow B. IV
Tangunan, Priscilla L.
Tapley, David R.
Thomas, W. A1
Thompson, Thomas P. Jr.
Trieschmann, John W.
Tucker, R. Paul
Vallery, Samuel W.
Wallace, Thomas
Walley, Luther R.
Warren, E. Taliaferro
Warren, William Jr.
Watermann, Eugene
Webb, Timothy
Weyrich, Randall P.
Woodward, Philip A.
Wright, Charles C.
Young, Michael J.
Grant County
Covington, Brenda K.
Irvin, Jack M.
Paulk, Clyde D.
Winston, Scott D.
Greene-Clay County
Baker, Clark M.
Boggs, Dwight F.
Bonner, J. Darrell
Cagle, Roger E.
Collier, George H. Jr. #
Collier, Jon D.
Crow, Asa A.
Duckworth, Hillard R.
Fonticiella, Adalberto
Eonticiella, Aldo V.
Hardcastle, R. Lowell
Hazzard, Marion P
Volume 93, Number 7 - December 1996
359
Hobby, George A.
Jackson, Ron
Kemp, Clarence
Lawson, J. Larry
Martin, Richard O.
Mitchell, Bennie E.
Morrison, Jimmy J.
Muse, Jerry L.
Page, Billie C.
Perry, Evelyn S.
Perry, John K.
Purcell, Donald 1.
Rollins, William
Sellars, John R.
Shedd, Leonus L.
Sheridan, James G.
Shotts, C. Mack Jr.
Shotts, Vern Ann
Smith, Norman E.
Watson, Samuel D.
White, Robert B.
Williams, Dwight M.
Williams, Jacob M.
Hempstead County
Finley, George
Harris, Lowell O.
Holt, Forney G.
Johnson, David L.
McKenzie, Jim
Portis, Richard P.
Stevens, David G.
Wright, George H.
Hot Spring County
Berry, Frederick B.
Bollen, A. Ray
Brashears, Larry B.
Burton, Bruce K.
Cobb, Russell W
Ellis, C. Randolph
Highsmith, Vivian F.
Kersh, N. B.
Lumb, John C.
Peters, Claude F.
Tilley, Absalom
Vaughan, John A.
White, Bruce A.
White, Robert H.
Howard-Pike
County
Dunn, Robert
Floyd, Mark A.
Gullett, A. Dale
Humphreys, T. J. Jr.
King, Joe D.
Martinazzo-Dunn, Anna
Peebles, Samuel W.
Sayre, John
Sykes, Robert
Turbeville, James O.
Ward, Hiram T.
White, Phillip L.
Independence
County
Alexander, William Steve
Allen, James D.
Angel, Jeff D.
Baker, John R.
Baker, Robert V.
Bates, Ronald J.
Beck, James F.
Bess, Lloyd G.
Brown, Hunter Lee
Brown, Verona T.
Cummins, Thomas
Davidson, Andy
Davidson, Dennis O.
Fowler, William
Goodin, William H. Jr.
Hays, Sarah F.
Jeffrey, Jay R.
Johnson, Deborah A.
Jones, Edward J.
Jones, Edward T.
Joseph, Aubrey S.
Kearns, Harry
Ketz, Wesley J.
Lambert, John S.
Lytle, Jim E.
McClain, Charles M. Jr.
Melton, Clinton G.
Moody, Lackey G.
Neaville, Gregory
O'Brien, Marcus D.
Piediscalzi, Nicholas
Scott, John G.
Simpson, Ronald
Slaughter, Bob L.
Sloan, Fredric J. II
Stalker, James M.
Sutterfield, Terry F.
Taylor, Chaney W.
Taylor, Charles A.
Van Grouw, Richard
Waldrip, William J. Ill
Walton, Robert B.
Webster, Russell P.
Williams, Robin C.
Jackson County
Ashley, John D. Jr.
Carney, J. W. #
Chauhan, Mufiz A.
Dudley, Guilford M. Ill
Falwell, K. Wade
Frankum, Jerry M. Jr.
Fremming, Bret G.
Green, Roger L.
Hergenroeder, Paul J.
Hunt, Randall Evan
Jackson, Jabez Fenton Jr.
Junkin, A. Bruce
Molnar, Istvan
Montgomery, F. Renee'
Poon, Hon K.
Reynolds, Roland C.
Snodgrass, Phillip A.
Young, Jack S. Ill
Ziebold, Christine S.
Jefferson County
Alexander, Lester T.
Ancalmo, Nelson
Anderson, Charles W.
Armstrong, Simmie Jr.
Atiq, Omar T.
Atkinson, Robbie
Atnip, Gwyn
Attwood, H.
Baho, Haysam
Bell, Carl H. Jr.
Bitzer, Lon
Blackwell, Banks
Bracy, Calvin M.
Brooks, R. Teryl Jr.
Broughton, Stephen A.
Bruton, J. Lewis
Buckley, J. Wayne
Busby, John
Butler, Robert C.
Campbell, James C. Jr.
Carlton, Irvin L.
Cash, J. Steven
Cheek, Ben H.
Clark, Charles A.
Cook, Jonathan M.
Courtney, Willis Jr.
Crenshaw, John
Davis, Charles M.
Davis, Paul W.
Dedman, John D.
Del Giudice, Jose A.
Deneke, William
Dharamsey, Shabbir A.
Duckworth, Thomas S.
Dunaway, Joseph D.
Fendley, Ann E.
Fendley, Claude E.
Fendley, Herbert F.
Flowers, Martha A.
Forestiere, Lee A.
Freeman, William H.
Frigon, Jacquelyn S.
Green, Horace L.
Gullett, Robert R. Jr.
Herzog, John L. Sr.
Hughes, L. Milton
Hussain, Shafqat
Hutchison, E. L.
Hyman, Carl E.
Irwin, Raymond A. Jr.
Jacks, David C.
Jacks, Dennis
James, William J.
Jenkins, Bobby
Jenkins, Mary Ellen
Johnson, Horace
Jones, James III
Justiss, Richard D.
Khan, Mahmood A.
King, Yum Y.
Langston, Lloyd G.
Ligon, Ralph E.
Lim, William N.
Lindsey, James A.
Lum, Don
Lupo, David A.
Lytle, John O.
Mabry, Charles D.
Malik, Shamim A.
Marcus, Herschel
McDonald, Robert L.
McFarland, Mike S.
Meredith, William R.
Miller, Donald L.
360
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Milligan, Monte C.
Mohiuddin, Mohammed J.
Mohyuddin, Adil Ibrahim
Morris, Harold J.
Mulingtapang, Reynaldo F.
Nagappa, Champa
Newan, Michael
Nixon, David T.
Nixon, William R.
Nuckolls, J. William
Orange, Betty L.
Pearce, Malcolm B.
Pierce, J. R. Jr.
Pierce, Reid
Pierce, Ruston Y.
Pollard, J. Alan
Quimosing, Estelita M.
Redman, Anna T.
Reid, Lloyene B.
Rhode, Marvin C.
Roaf, Sterling A.
Roberson, George V. Jr.
Robinson, Paul F.
Rogers, Henry L.
Rook, Michael J.
Ross, Robert L.
Rowe, David E.
Samuel, Ferdinand K.
Shorts, Stephen D.
Simmons, Calvin R.
Simpson, P. B. Jr.
Smith, Paul L.
Stark, James
Stern, Howard S.
Sullenberger, A. G.
Townsend, Thomas E.
Tracy, C. Clyde
Trice, James
Walajahi, Fa wad H.
Washington, Erma
Wilkins, Walter J. Jr.
Wineland, Herbert L.
Woods, Jerrye
Worrell, Aubrey M. Jr.
Johnson County
Goodman, James David
Kuykendall, Scott
McKelvey, Richard
Pennington, Donald H.
Shrigley, Guy P.
Tackett, Lee Jr.
Lafayette County
Harbin, Bradley
Lee, Willie J.
Lawrence County
Hughes, Joe E.
Joseph, Ralph F.
Lancaster, Ted S.
Quevillon, Robert D.
Spades, Sebastian A. Ill
Troxel, Roger
Lee County
Balke, Susan W.
Gray, Dwight W.
Ly, Duong N.
Waddy, Leon Jr.
Little River County
Armstrong, James #
Covert, George K.
Peacock, Norman W. Jr.
Shelton, Joseph Jr.
Logan County
Alexander, Eugene
Borklund, Maurice K.
Buckley, Douglas A.
Daniel, William R.
Enns, Wayne P.
Harbison, James D.
Hasan, Shahzad
Roberts, William J. #
Suguitan, Demetrio B. Jr.
Williams, John R.
Lonoke County
Abrams, Joe A.
Anderson, Leslie
Braswell, Thomas
Chapman, Jerry C.
Elam, Garrett
Holmes, Byron E.
Inman, Fred C. Jr.
Rochelle, Joe
Schumann, Gerald M.
Shurley, Floyd Jr.
Thomason, Steven L.
Valley, Marc A.
Miller County
Alkire, Carey
Andrews, A. E. Jr.
Barnes, Walter C. Jr.
Blackburn, Roy Manell
Burns, Billy R.
Burroughs, James C.
Campanini, D. Scott
Carlisle, David L.
Chandler, Rodney
Collins, Stanley
Cutler, Otis
DeHaan, Jeffrey T.
Dildy, Edwin V. Jr.
Ditsch, Craig E.
Dodd, N. Leland
Dodge, John M.
Eichler, Edward A. Jr.
Ekanem, Felix
Ford, John Suffern
Fournier, Donald C.
Gabbie, Mark
Gillean, John A.
Godo, John C.
Graham, John
Green, R. Clark
Gregory, John R.
Griffin, Nancy
Hall, Eric E.
Harris, C. Lynn #
Hillis, Thomas M.
Hollingsworth, Charles E. II
Hughes, A. Keith
Jean, Alan B.
Jones, John W.
Joyce, F. E.
Kittrell, James
Knowles, Stanley C.
Loe, Arlis W.
McGinnis, Robert S. Sr.
Melton, Charles L.
Morris, Howard
Newton, Norris L. Sr.
Newton, Norris L. Jr.
Norris, John A.
O'Banion, Dennis
Peebles, Larry M.
Price, Kevin S.
Robbins, Joseph
Robertson, William
Robinson, Dianna L.
Rountree, Glen A.
Royal, Jack L.
Sarna, Paul D.
Sarrett, James
Shipp, G. Carl
Smith, Arnett D. Jr.
Smith, Christopher T.
Smolarz, Gregory J.
Solomon, J. Alan
Somerville, Patrick J.
Stringfellow, Jerry B.
Tompkins, William Jr.
Vereen, Lowell E.
Wade, Billy
Wilhelm, Frieda
Wilson, Thomas Laurence
Wren, Herbert B.
Wren, Mark
Wright, Mark
Wright, Nathan L.
Yarbrough, Charles P.
Young, Mitchell
Mississippi County
Abraham, Anes Wiley
Abramson, Lawrence
Bell, Mary C.
Biggerstaff, Jerry
Brock, Charles C. Jr.
Cullom, Sumner R.
Fairley, Eldon
Fergus, R. Scott
Grissom, David B.
Hall, Leslie
Haynes, Max G.
Hester, Karen Calaway
Hester, Richard
Hubener, Louis F.
Hudson, James H.
Husted, G. Scott
Jones, Herbert
Jones, Joe V.
Lin, Ching-Shan
Lowery, Russell
Osborne, Merrill J.
Pollock, George D.
Rhodes, Joseph
Rodman, T. N.
Russell, James D.
Shahriari, Sia
Shaneyfelt, E. A.
Smith, Ronald D.
Williams, John
Yao, Joseph
Monroe County
Campos, Amador
Volume 93, Number 7 - December 1996
361
Collins, Linda
David, Neylon C. Jr.
Pham, Dac Tat
Pupsta, Benedict F.
Stone, Herd E. Jr.
Walker, Walter L.
Ouachita County
Alhariri, Mirfat
Braden, Lawrence F.
Brunson, Milton
Crump, Mark
Daniel, William A.
Dedman, William D.
Floss, Robert
Fohn, Charles H.
Guthrie, James
Hopson, Deanna
Hout, Judson N.
Jameson, John B. Jr.
Kendall, Jerry R.
Martin, Dan
McFarland, Gale
Miller, John H.
Mosley, David
Nunnally, Robert H.
Ozment, L. V.
Sanders, Cal R.
Shrestha, Bal Narayan
Thorne, Arthur E.
Phillips County
Athota, Prasad J.
Barrow, John H. Jr.
Bell, L. J. Patrick
Bell, L. J. Patrick II
Berger, Alfred A.
Cruz, Eduardo V.
Epstein, S. Mitchell
Faulkner, Henry N.
Frederick, William Ronald
Hall, Scott
McCarty, Charles P.
McCarty, Gordon E. Jr.
McDaniel, Marion A.
Michel, Harry
Miller, Robert D. Jr.
Paine, William T.
Patton, Francis M.
Rangaswami, Bharathi
Rangaswami,
Narayanaswami
Tan, Benjamin
Tucek, Ladd
Tukivakala, P. Reddy
Vasudevan, Kanaka
Vasudevan, P.
Winston, William II
Wise, James E. Jr.
Polk County
Beckel, Ron Jr.
Brown, David P.
Finck, John Henry
Fried, David D.
Lochala, Richard
McClard, Helen
Mesko, John D.
Sosa, Humberto J.
Tinnesz, Thomas
Wood, John P.
Pope County
Ashcraft, Ted
Austin, Nathan
Bachman, David S.
Barron, William G.
Barton, A. Dale
Battles, Larry D.
Beavers, H. Kevin
Bell, Linda O.
Bell, Michael
Bell, Robert A.
Berner, Dennis W.
Birum, Patricia J.
Bradley, Stanley C.
Brown, Charles H.
Brown, William Bruce
Burgess, James G.
Callaway, Jody C.
Carter, James M.
Cloud, Joe A.
Crouch, James Jr.
Crumpler, Joe B. Jr.
Cunningham, James A.
Dunn, Donald L.
Ewing, Donald C.
Eerris, Craig A.
Erais, Michael A.
Galloway, William W.
Gately, Stanley
Haines, Lynn
Hale, Jeffrey
Harden, V. Anthony
Harrison, Rick
Henderson, Vickie L.
Hendren, Mike
Hill, Donald F.
Hines, Cynthia C.
Honghiran, Ted
Jones, Charles Jr.
Kerin, Douglas
Khan, Gul Rukh
Killingsworth, Stephen M.
King, John W.
King, W. Ernest Jr.
Kolb, James M. Jr.
Kriesel, Ben J.
Lawrence, Erank M.
Lovell, Richard K. Sr.
Lowrey, Douglas H.
Lyford, Joe H. Jr.
Massey, V. Rudolph
Mauch, E. Jane
May, Robert H. Jr.
McCraw, Barry W.
Meyer, Kelly H.
Miller, Mark E.
Monfee, Andrew M.
Murphy, David S.
Myers, J. Mark
New, Kenneth O.
Richison, George C.
Rickey, Jean M.
Riddell, C. Michael
Riley, Don C.
Robertson, William T.
Soto, Sergio F.
Stolz, Gerald A. Jr.
Stone, Timothy
Tapley, Thomas S.
Teeter, Stanley D.
Thurlby, W. Robert
Turner, Finley P. II
Turner, Kenneth B.
White, Ronald
Wilkins, Charles F. Jr.
Williams, David M.
Williams, Thomas C.
Young, Sandra S.
Pulaski County
Abbott, William W. #
Abel, Lee C.
Abraham, Dana C.
Abraham, James H.
Abraham, James H. Ill
Ackerman, William E. Ill
Adametz, James
Adametz, John Sr.
Adametz, Kimberly
Adams, Christopher
Adamson, James
Alexander, Albert S.
Alford, T. Dale
Allen, Durward Jr.
Allen, John E. Jr.
Alston, Phillip
Amir, Jacob
Aquino, AI
Araoz, Carlos
Archer, Robert L.
Armstrong, Howard
Arrington, Robert
Astle, Hal
Atha, Timothy C.
Atkinson, William Jr.
Baber, John C. Jr.
Baber, John T.
Backus, Joe T.
Bailey, H. A. Ted Jr.
Baker, Glen F.
Baker, John W.
Baker, Johnson
Baldwin, Maxwell R.
Ball, Charles W. Jr.
Baltz, Brad Patrick
Barber, Jeffrey
Barber, Laurie
Barclay, David
Bard, David S.
Bard, John L.
Barger, Denver L.
Barlow, Brian E.
Barnes, C. Lowry
Barnes, Reginald
Barnes, Robert W.
Barnett, David
Barnett, Troy F.
Barron, Edwin N. Jr.
Bartnicke, Benjamin J.
Barton, Gary
Baskin, Barry
Bates, Ramona
Bates, Stephen
Batres, Francisco
Bauer, David
Bauer, F. Michael
Bauer, Frank M. Jr.
Bauman, David C.
Bayliss, John M.
Beadle, Beverly
362
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Bearden, James R.
Beaton, J. Neal
Beau, Scott
Beck, Joseph II.
Becquet, Norbert J.
Belknap, Melvin L.
Bell, Rex H.
Bennett, Eaton W.
Bennett, F. Anthony Jr.
Benton, William
Berry, Robert L.
Bevans, David W. Jr.
Bienvenu, Gregory
Bienvenu, Harold G. III.
Bierle, Michael
Billie, James
Biondo, Raymond V.
Birkett, Ian McRae
Bishop, Lisa M.
Bishop, William B.
Biton, Victor
Black, H. Thurston #
Blackshear, Jack L. Jr.
Blair, Susan
Blankenship, William F.
Blasier, R. Dale
Boehm, Timothy
Boellner, Samuel W.
Boger, James E.
Book, Lindy
Boop, Frederick
Boop, Warren C. Jr.
Bornhofen, John H.
Bost, Roger B.
Bourne, David E.
Bowen, W. Scott
Bower, Charles M.
Boyd, Charles M.
Bradburn, Curry B. Jr.
Bradford, J. David
Bradley, Joe F.
Brainard, Jay O.
Bratton, Nita
Bressinck, Renie E.
Brewer, Robert
Brewer, Thomas E.
Brimberry, Ronald K.
Brineman, John
Brinkley, Roy A.
Brizzolara, A. J.
Brizzolara, John Paul
Broach, R. Fred
Broadwater, John Ralph Jr.
Brown, Michael
Brown, Pamela S.
Brown, Randel
Brown, Steven L.
Browning, Donald G.
Browning, Stanley K.
Bruce, Thomas A.
Brunson, Ashley
Bryan, James W. IV
Buchanan, Francis R.
Buchanan, Gilbert A.
Buchman, Joseph A.
Buchman, Joseph K.
Bucolo, Anthony P.
Buford, Joe L.
Burger, Robert A.
Burnett, Hugh F.
Burnett, P. Susan
Burrow, Dennis R.
Butcher, Joan R.
Byrum, Jerry
Calcote, Robert A.
Calderon, Vincent Jr.
Calhoon, J. Dale
Calhoun, Joseph D.
Calhoun, Richard A.
Calkins, Joe B. Jr.
Campbell, Gilbert S.
Campbell, James W.
Campbell, Leah S.
Caplinger, Kelsy J. Ill
Capps, Dwight II
Carfagno, Jeffrey
Carle, Scott W.
Carson, Layne E.
Carter, Jerry L.
Carttar, Charles
Caruthers, Carol
Caruthers, Samuel B. Jr.
Casali, Robert E.
Cash, Darlene
Casper, Robert B.
Casteel, Helen
Cathey, Janet
Cathey, Steven
Chai, Sandra
Chakales, Harold H.
Chandler, Billy M.
Chappell, Carol W.
Cheairs, David B.
Cheairs, John T.
Chisholm, Dan P.
Choate, Robert B.
Christian, John D.
Christiansen, Stephen P.
Christy, George W.
Chudy, Amail
Church, Marion M.
Church, Michael
Clark, J. Roger
Clark, Richard B.
Clift, Steven A.
Clifton, Cliff
Clogston, Charles W.
Cobb, Jock S.
Cockrill, H. Howard Jr.
Cogburn, Bob E.
Colclasure, Joe B.
Collins, David
Collins, Kevin J.
Colwell, Karen Louise
Cone, John
Contrucci, Ann L.
Cook, Timothy R.
Cope, Michael
Corbitt, Mary
Cornell, Paul J.
Cosgrove, Kingsley W. Jr. #
Coussens, David M.
Crawford, Cary M.
Crews, J. Travis
Crocker, Charles H.
Cross, J. B.
Crow, Joe W.
Crow, R. Lewis Jr.
Crowell, Karen D.
Curtner, Byron D.
Darwin, William G.
Daugherty, Joe D.
Daugherty, John L.
David, Alex
Davie, Melanie
Davila, David G.
Davis, Glenn R.
Davis, J. Lynn
Dean, David M.
Dean, Gilbert O.
Deaton, C. William Jr.
Deer, Philip J. Jr.
Deer, Philip James III
Dennis, James L.
DesLauriers, S. Killeen
Dickins, John R. E.
Dickins, Robert D. Jr.
Dickson, D. Bud
Dillard, Daniel C.
Diner, Bradley
Dixon, Keith A.
Dodd, Doyne
Doncer, Richard P.
Doucet, Marlon J.
Douglas, Warren M.
Downs, Ralph A.
Dungan, William T.
Dwyer, Gregory A.
Eans, Thomas L.
Easter, Rex M.
Edge, Otis H.
Edmiston, Frank G.
Eisenach, R. Jeffrey
English, Jim
Eudy, Sidney
Evans, Billy
Evans, Samuel C.
Farmer, Joseph F.
Farque, Greg L.
Farris, Guy R. Jr. #
Fawcett, Deborah Dee
Fernandez, Agustin
Ferris, Ernest J.
Fewell, Ronald D.
Fielder, Charles R.
Fields, Patrick R.
Finan, Barre F.
Fincher, Robert L.
Fiser, Martin
Fiser, Robert H. Jr.
Fiser, William P. Jr.
Fitzgerald, Charles
Fitzhugh, A. Stuart
Flack, James V. Jr.
Flaming, Jay
Fletcher, Anthony
Fletcher, Elizabeth D.
Fletcher, Thomas M.
Florez, James P.
Floyd, Bill G.
Forte, Judith L.
Foster, Gil
Fraiser, Lacy P.
France, Gene L.
Fraser, Eric A.
Frazier, Cynthia
Frazier, G. Thomas
Freeman, Diane
Fuller, C. Dale
Fuller, C. James III
Fulmer, John M.
Galbraith, Robert C.
Volume 93, Number 7 - December 1996
363
Gardner, Guy R
Garrett, Nina
Gettys, Joseph M. Jr.
Gibbs, Mark
Giblin, John M.
Gibson, Gordon L.
Giglia, Anthony R. Ill
Giles, Wilbur M.
Gillespie, A. Tharp
Gilliam, David
Gist, Charles C.
Glenn, Wayne B.
Glidden, Michael L.
Glover, Lawson E. Jr.
Glover, W. Clyde
Golden, William E.
Goldsmith, Geoffrey
Gosser, Bob L.
Goza, George M. Jr.
Grant, Karen G.
Green, Benny J.
Green way, C. Don
Greenwood, Denise R.
Greer, G. Stephen
Greutter, John E. Jr.
Griebel, Jack A. Jr.
Grimes, H. Austin
Guard, Peggy K.
Guggenheim, Frederick G.
Guin, Jere D.
Gurley, Thomas D.
Hagans, James III
Hagler, James L.
Hahn, Herbert
Hall, A. D.
Hall, A. David
Hall, Gregory S.
Hall, R. Whit
Hamilton, George Jr.
Hampton, John R. Ill
Hankins, Edwin III
Hanna, Ehab
Harber, Harley
Hardberger, R. E.
Hardin, Robert
Hardin, Ronald D.
Harger, C. Harold
Hargrove, Joe L.
Harper, Gary E.
Harrendorf, Cagle
Harrington, Gregory S.
Harrington, Mariann
Hams, Donald R.
Harris, T. Stuart
Harris, W. Turner
Harrison, A. Vale
Harrison, Roy E.
Harrison, William
Harshfield, David Lee Jr.
Hart, Thomas M.
Harter, Scott
Hathcock, Stephen A.
Hauer-Jensen, Martin
Hawley, Harold B.
Hayden, William F.
Hayes, J. Harry Jr.
Hayes, Richard L.
Hayes, Sidney P.
Haynes, W. Ducote
Headstream, James W.
Heamsberger, H. Graves III
Hearnsberger, Henry G. Jr.
Heamsberger, John E.
Hedges, Harold IV.
Hedges, Harold H.
Hefley, Bill F.
Hefley, William Jr.
Henker, Fred O. Ill
Henry, C. Reid Jr.
Henry, Charles R. Sr.
Henry, D. Andrew
Henry, G. Michael
Henry, G. Morrison
Henry, J. Charles
Henry, J. Forrest Jr.
Henry, Richard Y.
Henry, William T.
Henson, Gregory N.
Herbert, R. Wayne
Herron, Jerry M.
Hickey, Joseph P.
Hicks, David C.
Hicks, David L.
Hixson, Marcia Lynn
Hodges, J. Timothy
Hodges, Steven C.
Hoffmann, Thomas H.
Holland, Jay D.
Holloway, J. Douglas
Holt, Stephen
Holton, Jerry C.
Hopkins, Karmen
Hough, Aubrey J. Jr.
Houk, Richard
Houston, Samuel
Howell, Coburn S. Jr.
Hudec, Regina
Hughes, Ronald D.
Hundley, Randal F.
Hurlbut, Kimberly
Hutchins, Laura
Hutchins, Steven W.
Hutson, Harold G.
Ingram, Jim
Jackson, J. Presley
Jackson, Thomas
Jansen, G. Thomas
Jefferson, Terry
Johnson, Anthony D.
Johnson, B. Richard
Johnson, Ben D.
Johnson, Carl
Johnson, Clifton R.
Johnson, Dianne Flowers
Johnson, Henry D.
Johnson, M. Bruce
Johnson, Philip H.
Johnston, Dale E.
Johnston, Kenneth
Jones, Eugene
Jones, Gail Reede
Jones, Garry L.
Jones, John C.
Jones, Kathleen C.
Jones, Robert D.
Jones, Roy Steven
Jones, S. Michael
Jones, William N.
Jordan, F. Richard
Jordan, Randy A.
Joseph, Ralph F. II
Joseph, William Frank
Jouett, W. Ray
Joyce, John W.
Junkin, Ruth H.
Kaemmerling, Raymond E.
Kahn, Alfred Jr.
Kamanda, Stella M.
Kane, James J.
Keeran, Michael G.
Keith, Sharon C.
Kellar, Stanley L.
Keller, Alfred W.
Keller, Kevin
Kennedy, Charles H.
Kennedy, Eleanor E.
Kennedy, H. Frazier
Ketcham, Jeffrey
Key, J. Michael
Kilgore, Reed W.
King, Michael T.
King, W. David
Kittler, Fred J.
Kizziar, Jim C.
Klein, E. F. "Bud" Jr.
Klimberg, V. Suzanne
Knott, Patricia A.
Knox, Michael F.
Kolb, Agnes J.
Kolb, David
Kolb, W. Payton
Koonce, Thomas W.
Kovaleski, Thomas M.
Kozlowski, Karen J.
Krulin, Gregory S.
Kumpuris, Andrew G.
Kumpuris, Dean
Kumpuris, Frank G.
Kyle, Joan E.
Kyser, J. Floyd
Laakman, Robert W.
Lambert, Robert A.
Landers, James H.
Landgren, Robert C.
Lane, John W.
Lang, Nicholas P.
Langford, Timothy
Lehmberg, Robert W.
Leibovich, Marvin
Leithiser, Richard Jr.
Leonard, Donald G.
Leou, Frank J.
Lewis, Derek
Lile, Henry A.
Lincoln, Ben M.
Lipke, Jay M.
Loebl, Edward C.
Logan, Charles W.
Love, Tommy L. Jr.
Lowe, Betty A.
Ludwig, Frank R.
Luttrell, Rex E.
Lyons, Virgle E. Jr.
Mabrey, William
Magie, Stephen K.
Mallory, John A.
Maloney, F. Patrick
Maners, Ann
Mann, R. Jerry
Marable, Charles T.
Markland, Gary S.
Marks, Stephen R.
364
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Martin, Kenneth A.
Martin, Richard H.
Marvin, Peter
Mason, J. Zachary
Mason, William L.
Matched, W. Jean
Matthews, Joseph W.
McAdoo, Hosea W. Jr.
McCarthy, Richard E.
McConnell, John D.
McCoy, Julia M.
McCracken, Gail Ann
McCracken, John
McCrary, George A.
McCutcheon, Frank B. Jr.
McDonald, James E.
McDonald, Judy
McGowan, Robert Jr.
McGrew, Robert N.
McKelvey, K. David
McKinney, Carl
McKinnon, L. Jane
McKnight, C. Allen
McLeane, Mark
McMahon, Robert M.
McMillin, F. Lamar Sr.
McNair, James R.
McNee, Valerie
McPeak, Lisa
Meacham, Donald F.
Meador, Annette Parker
Meadors, Frederick
Meadors, John
Medlock, Rickey D.
Mehta, Madhu
Mellor, Roy II
Mendelsohn, Lawrence A.
Metrailer, James A.
Metzer, W. Steve
Meziere, Tom
Miles, David A.
Miller, Forrest B. Jr.
Miller, Raymond P. Sr.
Milner, E. L.
Mitchell, George K.
Mizell, Philip
Mizell, Walter S.
Moffett, T. Robert Jr.
Money, Wandal D.
Montanez, Josue
Montgomery, Lori
Mooney, Donald K.
Moore, Burton A.
Moore, J. Malcolm Jr.
Moore, Michael
Moore, Rex N.
Moore, Robert B.
Moore, Thomas
Morris, Barbara
Morris, W. Dale
Morrison, Debra F.
Morse, James C.
Morton, William J.
Mulhollan, James S.
Mumme, David
Murphy, Bruce
Murphy, James E. Jr.
Murphy, Jeanne
Murphy, Joseph
Murphy, Randolph
Murphy, Robert
Nagel, Fred G.
Nance, Melvin E.
Nash, John C.
Nelson, Alvah J. Ill
Nelson, Carl L.
Nestrud, Richard M.
Newbern, D. Gordon
Newsum, Jon Kirby
Newton, Fred E.
Nguyen, Duong
Nichols, Roger D. II
Nichols, Sandra D.
Nix, Richard A.
Nokes, Steven
Norris, Lloyd P.
Norton, George A.
Norton, Joseph A.
Nowlin, James Bill
Nugent, Richard
Oates, Gordon P.
Oddson, Terrence A.
Oglesby, Walter R.
Osam, Patrick N.
Osteen, Paul
Overacre, Robert
Owen, Richard Jr.
Owings, Debra #
Owings, Richard
Ozment, Kerry
Padberg, Frank T.
Paddock, George
Padilla, Fernando
Pahls, Wendell Lee
Pappas, James J.
Parker, J. Mayne
Parker, Ray K.
Parkhurst, James
Parmley, Tim
Parnell, Clifton L. Ill
Paulus, Thomas E.
Payne, Cheryl
Pearce, Charles E.
Peek, Richard
Peeples, R. Earl
Peters, John E.
Peters, Phillip J.
Petrash, Anton Tony'
Petrus, Gary M.
Petursson, Gissur J.
Peyahouse, Joe
Phillips, Charles E.
Phillips, Hannah
Pierce, William
Pike, John D.
Pledger, Norman R.
Pollard, Arlee E.
Pollock, Michael Marion
Pope, David
Pope, Norton A.
Porter, Robert Jr.
Potts, Jerry L.
Power, Robert C.
Prather, Jerry L.
Primack, Daren S.
Pringos, Andrew A.
Pyle, Hoyte R. Jr.
Quirk, J. Gerald
Rahman, Holly
Ransom, John M.
Rapp, Richard J.
Raque, Carl J.
Ray, V. Gail
Rector, Nancy F.
Reding, David L.
Redman, John F.
Reed, Ewing C. Jr.
Reese, William G.
Reid, Gene W.
Remmel, Raymond
Rice, Charles
Rice, James Curtis
Rice, Robert L.
Riddle, John F. Jr.
Riley, William H.
Ritchie, Robert Ross
Robbins, Kenneth
Roberson, Michael C.
Roberts, Kevin
Robinson, Matthew
Rodgers, C. Dudley
Rodgers, Charles H.
Rooney, Thomas P.
Rosenbaum, Carl A.
Ross, Ashley Sloan
Ross, Cynthia
Ross, Robert W. #
Ross, S. William
Rounsaville, Harry L.
Roy, F. Hampton
Ruddell, Deanna N.
Ruggles, Dwayne L.
Runyan, William A. #
Russell, Anthony E.
Russell, James B.
Rutledge, William L.
Ryals, Rickey O.
Saer, Edward H. Ill
Safman, Bruce L.
Samlaska, Susan K.
Sanders, Kelli K.
Santoro, Ian H.
Satre, Richard W.
Schellhase, Dennis E.
Schlesinger, Scott Michael
Schock, Charles C.
Schratz, Bruce E.
Schroeder, George T.
Schultz, John C.
Sch wander, L. Howard
Schwankhaus, John D.
Scott, Don I.
Scott, Jane F.
Scruggs, Jan W.
Searcy, Robert M.
Seguin-Calderon, Rosa Elia
Seibert, Joanna J.
Seibert, Robert
Selakovich, Walter G.
Sessions, Louis II
Sheppard, Joseph
Shields, Eddie
Shock, John P.
Short, Harold K.
Shotts, Joseph
Shuffield, James
Silvoso, Gerald R.
Silzer, Robert R.
Simmons, Orman W.
Sims, James M.
Singer, Peter
Singleton, L. Gene
Volume 93, Number 7 - December 1996
365
Sinor Kennedy, Elicia
Sipes, Frank M.
Skokos, C. Kemp
Slater, John G. Jr.
Slaven, John E.
Slayden, John E.
Sloan, Eugene E.
Sloan, Fay M.
Smart, Douglas F.
Smelz, Johnny
Smith, Aubrey C.
Smith, Charles W.
Smith, David E.
Smith, Douglas B.
Smith, G. Richard Jr.
Smith, James L.
Smith, Purcell Jr.
Smith, Thomas J.
Smith, Thomas W.
Smith, Tom
Smith, Vestal B. Jr.
Snyder, Steven D.
Snyder, Victor F.
Somers, A. Jack
Sorrells, R. Barry
Sotomora, Ricardo F.
Squire, Arthur E. Jr.
St Amour, Thomas E.
Stallings, James Walt
Stanley, Joe P.
Stanley, Robert
Stefans, Vikki Ann
Stephens, Wanda
Stern, Scott Jeffrey
Sternberg, Jack J.
Stewart, Daryl
Stewart, Marguerite R.
Stinnett, Thomas
Stokes, B. Douglas
Storey gard, Alan R.
Stotts, John R.
Stout, Kimber
Strauss, Mark
Stringer, Warren
Strode, Steven W.
Stroope, George F.
Studdard, James D.
Sturdivant, Stephen
Suen, James
Sulieman, J. Samir
Sullivan, Charles D.
Sullivan, Jan R.
Sundermann, Richard H.
Talbert, Gary Eugene
Talbert, Michael L.
Tamas, David E.
Tanner, James A.
Taylor, David R.
Taylor, Eugene H.
Tedford, John G.
Tharp, John G.
Thomas, A. Henry
Thomas, Peter O.
Thompson, John R.
Thompson, S. Berry Jr.
Thompson, Steven M.
Thomsen Hall, Kathleen
Thorn, G. Max
Thrower, Rufus
Tilley, Steve
Tolleson, Claudia
Towbin, Eugene J.
Tracy, Phillip A.
Tranum, Bill L.
Tressler, Samuel D. Ill
Trigg, Laura
Tseng, Jyi-Ming
Tucker, R. Stephen
Tucker, W. Everett
Valentine, Robert G. Jr.
Van Zandt, Janelle
Vaughter, W. Roger
Velez, L. Duane
Vinsant, Kurtis
Vogel, Robert G.
Wade, William I. Jr.
Wagoner, Jack
Walker, Lee
Walker, Ronald
Walt, James R.
Waner, Milton
Ward, Harry P.
Ward, Joseph P.
Ward, Thomas
Warford, Walton R. #
Watkins, Charles J.
Watkins, John Jr.
Watkins, John G. Ill
Watkins, Julia
Watkins, Larry S.
Watson, Daniel W.
Watson, Vye B.
Weber, Edward R.
Weber, James R.
Weber, Michael
Weiss, David W.
Weiss, Gerald N.
Welch, Samuel Bradley
Wellons, James A. Jr.
Wende, Raymond A.
Wenger, Carl E.
Westbrook, Kent C.
Westbrook, September
Westerfield, Frank M. Jr.
Westerfield, Robert
White, Oba B.
Whiteside-Michel, Julia
Wilkes, Elbert H.
Wilkes, T. David I.
Williams, Alonzo D.
Williams, C. David
Williams, G. Doyne Jr.
Williams, Paul E.
Williams, Ronald N.
Williamson, Adrian III
Wills, Pamela
Wilson, Elaine
Wilson, Frances C.
Wilson, Frank J. Jr.
Wilson, I. Dodd
Wilson, James Michael
Wilson, James W.
Wilson, John L.
Wilson, R. Sloan
Wolverton, John
Workman, W. Wayne
Wortham, Thomas H.
Wyatt, Richard A.
Yamauchi, Terry
Yaseen, Mohammad
Yee, Suzanne
Yocum, John
Young, Douglas E.
Young, Evelyn
Yousuff, Sarah S.
Ziller, Stephen A. Ill
Ziomek, Stanley
Randolph County
Baltz, Albert L.
Barre, Hal S.
Corcoran, Gavin R.
DeClerk, Thomas
Guntharp, George
Holt, Danny B.
Jansen, Andrew J. Ill
Landis, Mark A.
Scott, William W.
Smith, Norman K.
Saline County
Albey, Mark
Baber, Quin M.
Beard, Michael R.
Bethel, James
Boyle, Ronald H.
Burba, Alonzo R.
Burton, Charles R.
Caldwell, David L.
Cash, Ralph D.
Cathcart, Evelyn
Chaffin, Raines
Coker, S. Dale
Cooper, James B.
Council, Robert A. Jr.
Dockery, Melissa
Duncan, J. Shelby
Eaton, James M.
Enderlin, Annette
Gardner, Dan R.
Harper, Donald
Hill, Edward B.
Hill, Howell V.
Hogue, F. Paul
Izard, Ralph S. Jr.
Johnston, Greg
Kirk, Marvin N. Jr.
Martindale, J. L.
Martindale, Mark A.
Menard, John C.
Ramsay, Rex C. Jr.
Schmidt, Michael J.
Stanford, Royce Allan Jr.
Steele, William L.
Stewart, David L.
Sudderth, Brian F.
Taggart, Sam D.
Thibault, Frank G. Jr.
Thomas, Bill R.
Thorn, Harvey Bell Jr.
Tilley, Roger L.
Vice, Mark
Viner, Donald L.
Wagner, Taylor
Watson, Kirk D.
Wright, John D.
Sebastian County
Acklin, Jimmy D.
A1 Mounajed, Ghanem
Al-Ghussain, Emad A.M.M.
Albers, David G.
Alberty, Joe
366
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Anderson, Paul
Armstrong, Sinclair Jr.
Atkins, Jimmie G.
Axelsen, Nils K.
Bailey, Charles W.
Baker, Max A.
Balsara, Zubin
Barker, Robert Jr.
Barnes, L. Ford
Barr, Marilyn
Barry, James Jr.
Barsik, Tamara
Beachy, Allen L.
Beene-Lowder, Hannah L.
Berry hill, Richard E.
Berumen, Mike
Best, Timothy R.
Beyer, H. Stephen
Bise, Roger N.
Bodiford, Gary L.
Bordeaux, Ronald A.
Bouton, Michael
Bradford, A. C.
Brown, Byron L.
Brown, James A.
Brown, Richard
Buie, James H.
Builteman, Cynthia
Builteman, James
Burks, Deland
Busby, J. David
Cain, Martin
Callaway, Michael
Carson, Randall L.
Cassady, Calvin R.
Cesar, Luis Geraldo G.
Chalfant, Charles
Chester, Robert L.
Cheyne, Thomas
Chosney, Bruce
Coffman, Edwin L.
Coleman, Michael D.
Cook, Charles
Craft, Charles
Crow, Neil E. Sr.
Crow, Neil E. Jr.
Culp, William C.
Davenport, O. Leo
Deaton, John M.
Deneke, James S.
Diment, David D.
Dorzab, Joe H.
Drolshagen, Leo F. Ill
Dudding, William F.
Edwards, Gary
Ellis, Homer G.
Ennen, Randy
Eeder, Frederick P. Jr.
Feezell, Randall E.
Eeild, T. A. Ill
Felker, Gary V.
Eerrell, Jeffrey
Eisher, Robert D.
Flanagan, A. Dean
Fleck, Randolph Peter
Fleck, Rebecca
Flippin, Tony A.
Florian, Thomas
Floyd, Charles H.
Francis, Darryl R. II
Franz, F. Perry
Frederick, James A.
Gamble, Cory
Gardner, Kenneth
Gedosh, Edgar A.
Gill, James A.
Girkin, R. Gene
Glover, D. Bruce
Goodman, R. Cole Jr.
Goodman, Raymond C. Sr.
Griggs, William L. Ill
Gwartney, Michael P.
Hamilton, Lance
Hanley, Larry L.
Harmon, Pamela
Harris, Shirley D.
Hathcock, Alfred B.
Hendrickson, Jon
Henry, James
Herren, Adrian L.
Hewett, Archie L.
Hewett, Mark Alan
Hoffman, John D.
Hoge, Marlin B.
Holmes, Williams C. Jr.
Hornberger, Evans Z. Jr.
Howell, James T.
Hughes, Robert P. Jr.
Hunton, David W.
Huskison, William T.
Ihmeidan, Ismail H.
Ingram, Ralph N.
Irwin, Peter J.
Jaggers, Robert
Janes, Robert H. Jr.
Jefferson, Thomas C.
Jones, Greg T.
Kannout, Eareed
Kareus, John L.
Kelly, Thomas C.
Kelsey, J. F.
Keyashian, Mohsen
Kientz, John Jr.
Klopfenstein, Keith
Knight, William E.
Knox, Robert
Knubley, William A.
Kocher, David B.
Koenig, Albert S. Jr.
Kradel, R. Paul
Kramer, Ralph G.
Kutait, Kemal E.
Kyle, W. Lamar
Lambiotte, Louis O.
Landherr, Edwin
Landrum, Samuel E.
Lane, Charles S. Jr.
Lenington, Jerry O.
Lewis, George L.
Lilly, Ken E.
Little, Charles
Lockwood, Erank M.
Long, James W.
Loyd, Gregory M.
MacDade, Albert D.
Magness, Jack L. Jr.
Manus, Stephen C.
Marsh, Michael A.
Martimbeau, Claude
Martin, Art B.
Martin, Rick
Marvel, Jeffrey
Mason, Clinton
Masri, Hassan M.
Mauroner, Richard F.
McCarty, Joseph
McClain, Merle
McClanahan, J. David
McCraw, Gordon
McEwen, Stanley R.
McKinney, Robert
McMinimy, Donald
Meade, Arturo E.
Meador, Don M.
Mehl, John Kurt
Miller, Robert C.
Miller, Robert M.
Mings, Harold H.
Moore, Trudy J.
Moore-Earrell, Laura
Mosley, Myra C.
Moulton, Everett C. Jr.
Moulton, Everett C. Ill
Mumme, Marvin E.
Muylaert, Michel
Nassri, Louay K.
Nelson, Steve B.
Nichols, David R.
Niemann, Jeffrey M.
Nolewajka, Andre J.
O'Bryan, Robert K.
Olson, John D.
Paris, Charles H.
Parker, Joel E. Jr.
Parker, Thomas G.
Patrick, Donald L.
Pay son, Tony A.
Pearce, Larry W.
Peluso, Erancis
Pence, Eldon D. Jr.
Phillips, Don
Phillips, Kevin Clark
Phillips, Sumer
Phillips, Tonya
Pillstrom, Lawrence G.
Poole, M. Louis
Porter, Neill C.
Post, James M.
Prewitt, Taylor A.
Price, Claire
Price, Lawrence C.
Rabideau, Dana P.
Raby, Paul L.
Raymond, Thomas H.
Reese, Valerie
Rivera, Ernesto
Robinson, Ronald P.
Rodgers, Brian H.
Russell, Rex D.
Sanders, Robert E.
Sanders, Robert V. III.
Saviers, Boyd M.
Schemel, William H.
Schkade, Paul A.
Schmitz, James
Schroeder, Cygnet
Schwarz, Julio
Schwarz, Paul R.
Seffense, Stephen J.
Seiter, Kenneth
Shahbandar, A. B.
Sherrill, William M. Jr.
Volume 93, Number 7 - December 1996
367
Short, Bradley Mark
Smith, Kent
Smith, Terrald J.
Snider, James R.
St.Clair, Kevin
Standefer, J. Michael
Stanton, William B.
Stewart, Jerry R.
Stewart, John B.
Still, Eugene F. 11
Stillwell, Mark
Studt, James
Swicegood, John R.
Taft, Eileen
Taft, Eric
Tait, Amy
Teeter, Mark
Thompson, J. Kenneth
Thompson, Robert J.
Tinsman, Thomas
Tisdale, Bernard
Torres, Stephen
Turner, William R
Van Asche, Christopher
Vanderpool, Roy E.
Vernon, Rowland R Jr.
Waack, Timothy
Wallace, Kenneth K.
Webb, William K.
Weisse, John J.
Wells, John D.
Westbrook, Michael R.
Westerfield, Samuel
Westermann, Norman R
Whiteside, Edwin
Wikman, John H.
Williams, Carl L.
Wills, Paul I.
Wilson, Morton C.
Wolfe, Michael S.
Woods, Leon P.
Woodson, Mark
Wright, Timothy R
Zufari, Munir M.
Sevier County
Buffington, Mike
Couture, Susan E.
Hoyt, Jonathan
Jones, Charles N.
Jones, Thomas
Mielnick, Alina
Stearns, David E.
Vogan, Cheryl L.
Wilson, Timothy
St. Francis County
Collins, E. Morgan Jr.
Conner, George
Fong, Fun Hung
Guillermo, Enrique C.
Hammons, Edward P.
Hashmi, Shakeb
Iskander, Henein
Kumar, Sudhir
Lopez, Ramon E.
Meredith, James Jr.
Patton, W. Curtis
Schwartz, Frank R.
Webber, David L.
Tri-County
Arnold, Carl
Arnold, Griffin 11
Benton, Thomas H.
Bozeman, Jim G.
Campos, Louis
Grasse, A. Meryl
Jackson, George W.
Krygier, Albin J.
Lane, Robert G.
Moody, Michael N.
Relyea, William V.
Tatum, Harold M.
Tucker, Charles L.
Varela, Charles D.
Wright, Donald
Union County
Abbott, Judy
Anzalone, Gary
Arceneaux, Matt
Barenberg, Andrew
Barenberg, Robert
Bevill, Gary L.
Booker, J. Gregory
Bowman, Raymond N.
Bryant, D'Orsay III
Callaway, Matthew Dates
Carroll, Peter J.
Cyphers, Charles D.
Daniels, C. Dwayne
Davis, Richard K.
Deere, Joy
Dixon, R. Mark
Dougherty, Bert
Duzan, Kenneth R.
Elliott, Wayne G.
Ellis, Jacob P.
Fitch, Leston E. #
Forward, Robert B.
Fraser, David B.
Giller, W. John Jr.
Harper, William L.
Hill, Grady Jr.
Jenkins, Chester W.
Jones, Steve A.
Jucas, Diana T.
Jucas, John J.
Kang, Gurprem Singh
King, Billy D.
Landers, Gardner H.
Menendez, Moises A.
Moore, John H.
Murfee, Robert M.
Ong, Tie S.
Pillsbury, Richard C.
Pirnique, Allan S.
Ratcliff, John
Ray, Robin Phinney
Rogers, Henry B.
Sample, Dorothy C.
Sarnicki, Joseph
Schultz, Wayne H.
Scurlock, William R.
Seale, James E. Jr.
Sheppard, Julius
Smith, George W.
Sokolyk, Stephen M.
Stevens, Willis M. Jr.
Talley, H. Aubry
Tolosa, Elizabeth
Tommey, G. E.
Tommey, Robert C.
Turnbow, R. L.
Ulmer, Minna I.
Vasan, Srini
Warren, George W.
Weedman, James B.
Williamson, John R.
Wilson, Larkin M. Jr.
Yocum, David M. Jr.
Zahniser, Donna J.
Van Buren County
Hall, John A.
Pearce, Charles G.
Smith, James F.
Starnes, Harry
Washington County
Abernathy, Bryan
Albright, Spencer III
Allen, B. Eual
Applegate, C. Stanley Jr.
Arnold, James
Atwood, H. Daniel
Bailey, Donald G.
Bailey, Scott
Baker, C. Murl Jr.
Baker, Donald B.
Baker, James
Ball, Charles
Bays, L. Jerald
Beckman, James Jr.
Billingsley, John A. Ill
Blankenship, James
Bonner, Mark
Box, Ivan H.
Boyce, John M.
Bredfeldt, Raymond
Brooks, D. Wayne
Brooks, W. Ely
Brown, Bruce B. Jr.
Brown, Craig
Brown, David L.
Brunner, John A. Ill
Bugbee, William D.
Burnside, Wade W. Jr.
Burton, Anthony R.
Butler, G. Harrison
Gale, Charles
Cannon, Robert
Carver, Joel D.
Chase, Patrick R.
Cherry, James F.
Coker, Tom Patrick
Cole, George R. Jr.
Cooper, Craig
Councille, Clifford C. Jr.
Covey, M. Carl Jr.
Crittenden, David R.
Crocker, Thermon R.
Cross, Michael J.
Cunningham, Darrin D.
Danks, Kelly R.
Davis, David A.
Davis, Randall
Decker, Harold
Deen, Lewis S.
Denley, Thomas
Dodson, C. Dwight
Dorman, John W.
Duke, David D.
Duncan, Philip E.
Dykman, Thomas R.
Eck, Gareth
Edmondson, Charles T.
Fincher, G. Glen
Fink, Roger Lee II
Fish, Ted J.
Fossey, Carol
Gardner, Buford M.
Garibaldi, Byron T.
368
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Garner, Hershel H.
Ginger, John D.
Gray, Dalton L. II
Grear, Danna
Grote, Walton
Haisten, James
Hall, Ben
Hall, Joe B.
Hamilton, Herbert E.
Harris, David Jay
Harris, Murray
Harris, Paul L.
Harris, W. Duke
Harrison, William F.
Hart, Hamilton R.
Haynes, James
Hayward, Malcolm L. Jr.
Hedberg, Curtis
Heinzelmann, Peter R.
Hendrycy, Paul R.
Henry, Morriss M.
Higginbotham, Hugh B.
Higginbothom, William
Hoffman, Carl E.
Holden, Donnie
Hollomon, Michael
Hui, Anthony
Hurlbut, Kevin
Hutson, Martha
Hutson, Sanford E. Ill
Inlow, Charles W
Ivy, Donald
Jay, Gilbert D. Ill
Johnson, Miles M.
Knox, D. Luke
Koehn, Laura J.
Kraichoke, Saran
Landrum, Leslie G.
Levernier, James E.
Litton, Eva W.
Lloyd, Richard A.
Long, Robert M.
Magness, C. R.
Mahan, Meredith
Martin, F. Allan
Martin, William C.
Mashburn, James D.
McAlister, Joseph H.
McAlister, Mitchell
McBee, Sara
McDonald, James E. II
McElroy, Kellye
McEvoy, Francis
McGhee, Linda M.
McGowan, William
McNair, William R.
Miller, Charles H.
Miller, George
Mills, William C. Ill
Mitchell, Banford R. Jr.
Moon, Steven L.
Moore, Arthur F.
Moore, James F.
Morse, Michael
Murry, J. Warren
Nettleship, Mae B.
Nowlin, William B.
Ortego, Terry J.
Owens, Sherry L.
Pang, Robert
Park, John P.
Parker, Joe C. #
Parker, Lee B. Jr.
Patrick, James K.
Pesnell, Larkus H.
Pickett, James D.
Pickhardt, Mark G.
Pope, Kevin L.
Power, John R.
Proffitt, Danny L.
Raben, Cyril
Raben, Susan
Riddick, Earl B. Jr.
Riner, Dan M.
Rogers, David L.
Romine, James C.
Rosenzweig, Kenneth
Ross, Joseph
Rouse, Joe P.
Runnels, Vincent B.
Saitta, Michael R.
Sandefur, Barbara A.
Schemel, Lawrence J.
Schmidt, Clinton C.
Sexton, Giles A.
Sexton, Jon A.
Shaddox, T. Stephen
Sharp, Jim D.
Siegel, Lawrence H.
Simmons, Thomas
Simpson, Todd R.
Singleton, E. Mitchell
Sisco, Charles P.
Smith, Austin C.
Snyder, Norman I.
Stagg, Stephen W.
Strebeck, Sarah Lois
Taylor, Robert G.
Thomas, Joanna M.
Thorn, Garland M. Jr.
Titus, Janet L.
Tomlinson, Robert J. Jr.
Turner, Sam
Tuttle, Larry D.
Ubben, Kenneth
Ureckis, David
Ward, H. Wendell
Weed, Wendell W.
Weiss, John B.
Wheat, Ed Jr.
Whiteley, Andre
Whiting, Tom D.
Whitney, Richard N.
Wilson, Robert B. Jr.
Wood, Jack A.
Wood, Russell Hunter
Wood, Stephen T.
White County
Asmar, Salomon
Baker, Ronald L.
Bell, John
Blakely, Brent M.
Blickenstaff, Kyle R.
Blue, Glen T.
Blue, Leon R.
Brown, Arnold R.
Brown, Peggy J.
Brown, Terry Mac
Burns, Jerry
Citty, Jim C.
Collier, Steven F.
Covey, David C.
Davidson, Daniel
Elliott, Robert E.
Fincher, S. Clark
Formby, Thomas A.
Gardner, Jack R.
Gibbs, William M. Ill
Golleher, James H.
Harrison, Jack W.
Hatfield, David L.
Henderson, John C.
Holston, John S.
Jackson, Clarence W.
Johnson, David M.
Joseph, Eugene A.
Justus, Michael G.
Killough, Larry R.
Kinley, J. Garrett
Koch, Clarence W. Jr.
Lefler, Stephen F.
Lewing, Hugh S.
Lowery, Benjamin R.
Lowery, Robert D.
Maguire, Frank C. Jr.
McAdams, Edward L.
McCoy, James R.
Meacham, Kenneth R.
Millstein, David
Moore, Donald
Nevins, William H.
Norris, E. Lloyd
Ramirez, Raul
Ransom, Clarence E. Jr.
Rasberry, Ronnie D.
Rodgers, Porter R. Jr.
Schwartz, Stanley S.
Shultz, Sam L.
Simpson, James A.
Smith, Bernard C.
Smith, Bob W.
Staggs, David L.
Stinnett, J. L.
Tate, Sidney W.
Taylor, David H.
Thompson, Bruce
Weathers, Larry W.
White, William D.
White, William M.
Williams, W. Curtis
Yates, Terrence
Woodruff County
Hendrixson, Basil E.
Rowe, James E.
Yell County
Graves, Kim
Green, Terry G.
Hejna, Thomas
Hodges, Jerry F.
Isely, William A. Jr.
Luker, Jerome H.
Martin, Damon G. H.
Maupin, James L.
Pennington, James O.
Ring, Gene D.
Russell, Gary W.
Tippin, Philip
Direct Members
Abraham, Jacob E.
Agee, Kimberly R.
Ahmed, Sahibzada
Akkad, Nabil
Allard, Mark
Anderson, J. Roland
Anderson, Roger Wilbert
Andrews, Nancy R.
Angtuaco, Edgardo
Angtuaco, Edward E.
Volume 93, Number 7 - December 1996
369
Angtuaco, Sylvia
Antle-Vlach, Victoria J.
Arrington, James C.
Asbury, Dale W.
Ashabranner, Wesley J.
Asi, Wael
Atkinson, Evangelina
Bailey, Christopher A.
Baker, Kevin G.
Barone, Gary
Barrow, Robert
Bearden, Jeffrey C.
Beck, William A.
Beebe, William E.
Bennett, Anita
Benson, Eric Hamilton
Beverly, Carolyn
Blackstock, Terri
Blankenship, D. Michael
Bosch, Charles
Brannon, Dabney
Brodsky, Michael
Brooks, Andrew
Brown, Richard E. Jr.
Bryles, Robert S. #
Bumpers, Paul Jr.
Bushman, Gerald A.
Galicott, Timothy
Campbell, Charles E. Jr.
Campbell, James Jr.
Carey, Martin John
Carey, Victor Jr.
Carrick, Garreth
Carrico, John D.
Carroll, Barry
Carter, Inge Renate
Cherny, W. Bruce
Chitwood, G. Glen
Chu, Tommy D.
Clary, Cathy
Claycomb, Scott C.
Cofer, Thomas
Coffman, John L.
Collins, Gary James
Collins, Harold B. II
Cook, Joseph A.
Cook, Stephen
Coombe-Moore, Jackie
Cooper, Scott
Craytor, Bret F.
Crow, Ronald M.
Curtis, Mary A.
David, Wendy S.
Davis, Thomas J.
DeLoach, John Jr.
Devabhaktuni, Venu G.
Dickinson, Rodger C. Jr.
Dildy, Dale Jr.
Dinehart, Scott
Diner, Wilma G.
Dinulescu, Stefan Dan
Dobbs, John G.
Donovan, William
Doshi, Sangeeta H.
Drew, Mary Jo
Dunigan, Rodger
Duplantis, Kathryn
Economides, Nicholas
Edattukaren, Varghese
Edrington, David C.
Edwards, Peter M.
Edwards, Todd D.
El-Hayeck, Maroun
Eskandar, Ziad
Evans, Clifford L.
Eyre, Byron E.
Ezell, Gerry D.
Feild, Charles R.
Ferrer, Thomas J.
Finkbeiner, Alex E.
Fiser, Debra H.
Fitzgerald, Amy
Flamik, Darren E.
Flanagan, William H.
Flanigin, Richard
Florendo, Noel
Fontenot, H. Jerrel
Ford, Barry G.
Foreman, Riley D.
Fuerst, Erwin J.
Ganelli, Ronald R.
Garcia-Rill, Susan
Ghan, Sheryl E.
Gilbert, Jimmy
Glenn, Robert Edward
Gober, Gregg
Goodman, Jack
Gordon, Alfred Y. Jr.
Graham, Gharles J.
Grasse, John Jr.
Gregory, Jo Anne
Grisham, Dannetta
Gubin, Steven S.
Guevara, John
Gustavus, John L.
Haas, David G.
Handley, David L.
Haney, R. Kevin
Hardin, A. Scott
Hardy, Kyle G.
Harik, Sami I.
Harper, Richard
Harrell, James Jr.
Harris, Russell
Harrison, Lonnie Eugene
Hass, Farrell D.
Hatch, Allan B.
Hayes, John
Heim, Stephen
Henry, W. Bradley
Herring, Grady Jr.
Herrold, Jeffrey W.
Hicks, Charles E.
Hill, H. Randy
Hill, Joy
Hill, Shirlene B.
Hilman, Michael G.
Himmelstein, Stevan I.
Holloway, David Jr.
Hopkins, Robert Jr.
Hughes, Alan W.
Hughes, Juan
Hughes, Laurie O.
Hurley, James M.
Hutchison, George R.
Huynh, Chanh V.
Ibrahim, Manar S.A.
Ibsen, Michelle J.
Ismail, Hassan M.
Istanbouli, Wajih
Itzig, Gharles B. Jr.
Jabbour, J. T.
Jackson, Richard J.
Jaffar, Muhammed
Jasin, Hugo
Johnsrude, Christopher L.
Jones, Robert E.
Kale, Robert
Karassi, Malek S.
Katz, Stephen J.
Keeter, L. Phil
Kefri, Maher K.
Kelly, James E. Ill
Kendrick, Carl M.
Keplinger, Florian
Kerns, Kelly
Khan, Mohammed B.
King, William R.
Kinney, Joyce
Kirchner, Jeffrey
Knowles, Glen C.
Krisht, Ali F.
Lamb, Johnny Mack
Lang, Patricia A.
Lange, John L.
Lansford, Bryan
Lawson, William B.
LeBoeuf, Dorothy
Lehmann, Lance J.
Lewellen, Thomas Lynn
Lewis, Gharles
Lewis, James Sheridan
Lipsmeyer, Eleanor
Little, J. Aaron
Lockhart, William G. #
Lorenzo, Edilberto B.
Lowery, Ronald
Lyle, Robert
Lynch, Paula
Ma, Frank
Maes, LouAnn
Malik, Jacek Marian
Marshall, Byrne R.
Marshall, Glenn E.
Martin, Joan B.
Marvin, Michael
Mawulawde, Kwabena
Mayo, Russell
Mazursky, Jon E.
McGraham, Bethany Ann
McGrath, A. Joseph Jr.
McGuire, Samuel A. Ill
McKenzie, James
McMicheal, Wanda V.
Meador, A. Sharon
Meadors, Garol
Meredith, Paul D.
Miller, Laurence H.
Miller, Michael
Minnich, Thomas E.
Moore, Jesse
Moore, Jim J. II
Moore, Steven M.
Morgan, Martha
Moutos, Dean M.
Mullens, Mark
Munshi, Medha N.
MuriUo-Lopez, Fernando H.
Murray-Stephens, Andrea J.
Murry, William L.
Napolitano, Charles A.
Nelson-Adesokan, Paula M.
Nichol, Brian
Nichols, Scott
Nix, John E.
Norton, J.B. Jr.
O'Sullivan, Patrick J.
Osofisan, Olaniyi
Pace, Rose A.
Paine, Johnny R.
Papageorge, Dean
Parham, David M.
Parham, Groesbeck P.
Parker, A. Wade
370
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Paslidis, Nick J.
Pastor, Randy
Paul, William L.
Pearson, Fran
Pilkington, Cheryl E.
Pilkington, Neylon S.
Ploetz, Carina
Plunk, Hermie G.
Pohle, Floyd
Powers, Robert
Purnell, Gary L.
Quinn, Brian D.
Rader, George
Reddy, Krishna
Reid, Graham M.
Reis, Ivory
Robinson, Nancy
Rodkin, Richard S.
Romero, Alfred T.
Rozas, David
Rucker, Gari
Russo, William Louis
Salmeron, Manuel
Sanchez, Ilsa
Sangster, Michael
Sarinoglu, Cem
Schaefer, George
Schexnayder, Stephen M.
Schmidt, David
Seib, Paul M.
Sharma, Ranbir Kumar
Sheikha, Mouhammed K.
Shewmake, Kristopher B.
Shock, Melessa
Siegel, David S.
Sites, Terry Jay
Slezak, James
Smith, Kirby L.
Smith, Samuel D.
Snow, Sandra L.
Sorenson, Marney K.
Speed, Darrell
Spence, Don K.
Spiers, Jon P.
St. John, Melody
Stair, J. Michael
Starnes, C. Wayne
Stern, Thomas N.
Steward, Rodney Jr.
Stumer, William Q.
Suasin, Winlove B.
Tait, Layne
Talley, J. David
Tanner, Paul R.
Teal, Linda
Teo, Charles
Thompson, Jerome W.
Torres, Adalberto Jr.
Travis, Patrick
Trussell, Anne
Turner, Jan L.
Tutton, James
Utley, Phillip M.
Van Der Velden, Elaine M.
Van Hemert, Rudy
Van Noy, Joanna W.
Vasudevan, Padmini
Velusamy, Muthusamy
Vermont, Charles
Vogel, Eric D.
Vorhease, James W.
Wade, Walter Burke
Waheed, Atiya N.
Waldron, James A. Jr.
Washington, Mitzi A.
Waterhouse, Michael H.
Waters, Samuel
Webb, Malinda
Wendel, Paul J.
West, Joseph
Westwood, John Jr.
Wheeler, Richard
Whitaker, John
White, Paul C. Jr.
Willis, Charlotte
Wood, Michael D.
Woodson, Alexa
Wormuth, Christopher J.
Wylie, Paul
Yawn, Timothy
Yoser, Seth L.
Young, Michael C.
Yuen, James C.
Zangari, Maurizio
Zini, James E.
de Saint Felix, Douglas
Residents
Abu-Hamda, Emad M.
Adam, Walter M.
Adametz, John Jr.
Adams, Lennox R.
Adler, Ira
Albin, Amy Wilson
Alderink, Carlisle
Alfano, Thomas G.
Alley, Jerri
Andrews, Sean
Ansari, Mohsin K.
Arick, Carmen L.
Avva, Ramesh
Baho, Najla J.
Bailey, Don M.
Baker, Karen
Bakhtawar, Iram
Baldwin, Shelly
Balls, Luc G.
Baltz, Katherine
Barrett, Rebecca
Bauknight, Nichole
Bayer-Garner, Ilene Bertha
Bean, Paul E.
Beeman, David
Behrens, Bing X.
Berry, Michael F.
Bevans, David III
Bhutta, Adnan T.
Bigham, Lee IV
Bimie, Cynthia
Bivens, Marilyn
Blackwood, J'Ann B.
Bonwich, Janina R.
Boren, Edwin L.
Bowen, Bryan D.
Brady, John G.
Brandt, John O.
Brashears, Clay
Brewer, Jonathan K.
Brown, Robert D.
Bruffett, Wayne
Burke, Charles
Burks, Karen
Burr, William E. Jr.
Burton, Todd
Cain, Stephen R.
Caldwell, Charles R.
Cameron, Ricky L.
Carino, Richard
Carr, Russell S.
Cash, David
Cash, Paige P.
Ceola, Ashley
Ceola, Wade
Cerrato, Deborah
Cisneros, Teresa C.
Clark, Teresa
Colvin, G.B. 'Kip' IV
Connelley, Jay
Cooper, Keith
Coppola, Angelo Jr.
Corbell, Mark E.
Cottone, Joseph
Coutts, William II
Crafton, Eugene M.
Cruz, Lisa R.
Dale-Stewart, Casey
Dalton, Cara
Daniel, George K.
Danner, Christopher
Darby, Scott J.
Davis, Marc J.
DeFreese, Travis
Delap, Susan
Devabhaktuni, Nalini
Diamond, Corey
Diamond, Kevin
Dibrell, Fredrick
Dickson, Brian G.
Dicus, G. Scott
Dietz, Tracy
Diles, Timothy R.
Dillaha, Jennifer
Domon, Steven E.
Driskill, Angela
Duffield, Robin P.
Dugger, Joseph S.
Duke, John Richard
Dunn, James R.
Eads, Lou Ann
Ebsen, Tammy
Ehret, Rose
Elliott, Jana
Elnabtity, Mohamed
Emery, Robert
Endsley, Charolette
Erwin, John
Erwin, Steven
Esquibel, Ramona D.
Eyre, Marion D.
Fahr, Michael
Eant, Jerri S.
Farajallah, Awny
Farooque, Mustafa
Farst, Karen J.
Ferguson, Susan Portis
Fischer, Michael
Fiser, Richard
Fletcher, James W. Ill
Flippin, Dane
Fogata, Maria Luisa C.
Fortin, Elise
Frankowski, Gary
Franks, Hayden
Froman, Elizabeth A.
Gannon, Patrick R.
Garner, Kimberly
Garrett, George C. Jr.
Gati, Kenneth G.
Glasco, Gerry B.
Goodson, Timothy C.
Gordon, Anthony
Gordon, Gayle
Govindarajan,
Volume 93, Number 7 - December 1996
371
Rangaswamy
Graham, Richard
Grant, Jerry
Gray, Janet
Green, Cheryl
Gregory, J. Minor
Griffin, David
Grose, Andrew
Guerrero, David A.
Guevara, Doyle P.
Gutierrez, Miguel
Haight, Ann E.
Hale, Arthur E.
Halter, Charles
Hamby, Jeffrey
Handloser, Holly H.
Hardin, Christopher
Harrigan, Christopher
Hart, Susan K.
Hartman, Arthur R.
Harvey, Jerry L.
Hassan, Hassan A.
Hatcher, Alexander H.
Hatcher, Stacey L.
Hatfield, Patrick M.
Hatley, Russell
Hatley, Tina W.
Hays, David A.
Helsel, Jay C.
Hendrix, Barry
Hendrix, Lisa
Henry, Mary J.
Henry, Paul M.
Hernandez, Joseph M.
Hernandez, Nicole B.
Hester, Wes
Hiatt, Roger Jr.
Higginbotham, Michael
Hill, Chad
Hodge, Keith R.
Hodges, Michael E.
Hogan, Scott
Holleran, John R.
Hor, Michelle Kem
Hou, Di
Houston, Melinda L.
Hudec, Wayne
Hudson, Amy R.
Huey, Sandra S.
Iqbal, Imran
Jabben, Merten
Jackson, Charles A.
Jackson, Hugh
Jain, Pawankumav
Jamison-BIair, Beth
Jetton, Christina A.
Jewell, Shannon
Johnson, Brad D.
Johnson, Jennifer
Johnson, Michael W.
Jussa, Murad M.
Kassel, Gregory P.
Kelly, Patricia
Kempson, Steven E.
Kidd, Joseph Jr.
Kidd, Tracy L.
Kile, Herman L. Jr.
King, David
Kirchner, Jo Ann
Kirkland, Allan K.
Kiser, Thomas
Knight, Michael
Knutson, David L. II
Kohli, Manish
Kosuri, RamaKrishna
Lancaster, Shawn
Laughlin, Catherine L.
Leachman, Michael R.
Ledbetter, Johnny Jr.
Lewandowski,
Raymond C. Ill
Liu, George
Lorio, Allison G.
Lorio, Jerry J.
Loughman, Lisa
Lowery, Lisa
Lowther, Laura Marie
Lu, Eugene
Lucas, Shauna L.
Mallory, Michael D.
Malone, Mark S.
Manavalan, Pius Louis
Marchese, Sandra
Marfa tia, Vikram S.
Margaret, Heather
Markham, Larry
Marotti, A. Scott
Marotti, Tonya
Marshall, Marilyn D.
Massanelli, Gregg
Massey, Deborah A.
Massoll, Nicole A.
May-Wewers, Julie
Mayhew, Kathy
McAtee, James R.
McGhee, Michael A.
McKelvey, Kent D. Jr.
McLeod, Michael R.
McMahan, Steven
Merchant, Rhonda J.
Meyer, Christopher M.
Mhoon, J. Mark
Milligan, Lynda
Mitchell, Bruce
Mitchell, Rhonda K.
Mocharla, Raman
Moffett, Shirolyn R.
Mohan, Kumaran K.
Moix, Frank M. Jr.
Molette, Sekou F.M.
Moody, Melody
Moore, Glennal M.
Moser, Karl D.
Mukunyadzi, Perkins
Mullins, Michael
Mu walla, Firas R.
Neal, Marianne R.
Netterville, J. Kevin
Newman, Alan W.
Nguyen, Larry
Nighorn, Laura H.
North, Michael
Nutt, Angela
Over, Darrell R.
Palmer, Kristine G.
Parcon, Paul J.
Paredes, Mark F.
Perkins, Lalita
Perkins, Richard
Phillips, John D.
Phillips, Rebecca
Phillips, Tracy T.
Phomakay, Von
Pierce, Scott
Plovich, Regina M.
Prince, Audra M.
Prince, John R.
Purifoy, Shawn
Quade, Deborah
Quintero, Mauricio
Rahman, Salim
Ramanathan, Sundar R.
Ramsey, James R.
Rankin, Jay
Rayford, Richard
Rena, Diokson
Richey, Jason D.
Richter, Jon Kevin
Riley, Thomas O.
Roach, Milton III
Robertson, Donya
Rodgers, Benjamin L.
Rose, Steve
Roser, Steven
Rouse, Kevin
Runion, Lance
Russell, Debra
Russell, Shelley W.
Sambasivan, Arathi
Sanders, Scott
Sandor, Zsolt F.
Scott, Carla R.
Shaver, Mary
Shaver, Robert
Shen, Xingchu
Shihabuddin, Bashir
Shoppach, Jon Paul
Shutt, Bryce C.
Siems, Martin
Simpson, Laura
Singh, Baldev
Singh, Malwinder
Slack, Tobin A.
Slay, David
Smith, Daniel F
Smith, Matthew W.
Soderberg, Keith C.
South, Ronald
Sparling, Ed
St. Pierre, Mark
Steely, Donald
Stellpflug, Bradley S.
Stewart, Candace
Stewart, Casey D.
Stewart, Jason G.
Stewart, R. Todd
Stocks, Rose Mary
Stone, Ilya
Storey, Mark R.
Stout, Paul
Stussy, Shawn
Sutterfield, Vikki L.
Taylor, James
Taylor, Toby A.
Tharp, Paul S.
Thomas, Donald Jr.
Thomas, Jeffory
Thomas, Jonathan
Thomas, Lynn
Thompson, Rodney L.
Thorburn, Gerald M.
Thrasher, James R.
Tran, Viet N.
Travis, Theresa
Trevilliyan, M Jeanine
Veach, Paul A.
Velasquez, Lisa Ann
Vest, Carl E.
Viner, William E.
Wagner, Barbara R.
Walker, Brent
Ward, Susan
Ware, Gerald
Watson, Robert
372
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Webb, John
Webber, John C.
Wharton, James
White, Bradley
White, Gary
Whiteside, Thomas F. •
Wilbourn, Darin
Wilkin, Tim T.
Willhite, Andrea K.
Williams, Chrysti
Williams, Nancy K.
Williams, Robert S.
Williams, Victor
Wilson, Cynthia
Wilson, Matthew
Wilson, Patricia J.
Wood, W Rebecca
Woodard, Eric
Wooten, R. Gregory
Yeager-Bock, Angy
Yeates, Harry
Yeh, Y. Albert
Zacker, Stephen P.
Zelk, Misty M.
Zeni, Phillip Jr.
Zhou, Anthony
Students
Swihart, Camille H.
Adams, Stacie L.
Albertson, Christopher M.
Alberty, Brett L.
Allen, William W.
Archer, Walter C.
Arnold, James R.
Arthur, Lee E.
Baber, Kimberly D.
Bacon, Lori
Baker, Mark
Ballard, Devon R.
Baltz, Tracy C.
Banks, Holli N.
Banning, Michelle J.
Barboza, Jodi M.
Barnes, Jeanee' M.
Barr, Hilary
Barrow, John H.
Bean, Brian T.
Beck, Jason R.
Bell, Tanya R.
Belue, Kara D.
Bingham, D'Andra D.
Blackmon, Douglas M.
Blair, Brian H.
Blake, Dennis
Blankers, Christian G.
Boger, William G.
Braden, Chad C.
Brawley, Ashley M.
Bridges, James S.
Brock, Wade D.
Brown, Daniel K.
Brownfield, Shannon H.
Bryant, Bradley D.
Bryant, Christopher S.
Bryant, Gwendolyn M.
Bullard, Arlean R.
Burks, Jennifer E.
Burnett, Belinda A.
Bynum, Jody
Byrd, William G.
Cadle, Kimberly L.
Campbell, Rachel C.
Carlton, Randall D.
Carroll, Lori M.
Cate, Brian M.
Cathey, James D.
Cavaneau, Nick
Chambers, Sylvia D.
Charles, Rodney C.
Chavis, Brent D.
Chi, Jasen C.
Chrisman, Freddy D.
Chunn, Michael A.
Citty, J. Kris
Clardy, Bryan H.
Clements, Todd M.
Cobb, J. Chris
Cody, Stephanie G.
Coker, Raymond K.
Colclasure, Joe C.
Cole, David W.
Cole, Richard W.
Cooper, Kara L.
Cotner, James B.
Cowherd, Kristy
Cowherd, Robert M.
Cramm, Timothy L.
Crews, Tracy
Crisp, Constance J.
Crownover, David W.
Cullen, Robert D.
Dang, M. Yvonne
Dang, Minh-Tri
Daniel, Jamie
Dannaway, Douglas C.
Darr, James E.
Daut, Peter M.
Davis, John C.
Davis, Kimberly D.
Davis, Richard K. Jr.
Dawson, Justin D.
Dennington, Elvin L.
Denson, Alyson L.
Deuter, Brian E.
Dibble, Tim D.
Dickson, Scott M.
Dougals, Mary F.
Duke, Johnna L.
Dulin, William A.
Eads, Cheryl
Earl, Kevin S.
Ebert, Robert H.
Eckles, Laura L.
Eckles, Mike A.
Edwards, Clinton B.
Engelkes, LaDonna D.
England, Lane G.
Farrar, Jason
Ferguson, Lindsey N.
Ferguson, Philip E.
Finkbeiner, Andrew A.
Fisher, R. Scott
Flick, Julie L.
Fong, Shirley
Fornes', Daniel R.
Fox, Patrick J.
France, Vianne R.
Franks, Jason A.
Fuller, Jon D.
Fulmer-Massey, Laura A.
Furlow, John L.
Furlow, Stacy H.
Fussell, Jill D.
Cardial, Paul
Garrett-Shaver, Martha G.
Gaston, Caleb O.
Geoghagan, Jay
Gillian, Kris
Glover, Forrest D.
Glueck, Dane A.
Goad, James J.
Gollehon, Lena J.
Goosby, Nova D.
Gordon, Eric H.
Graham, Larry C.
Graves, Blane A.
Gray, Adam C.
Gray, David J.
Gray, Heather C.
Gregson, Ann-Marie
Griffin, Kristianne
Groves, Mary E.
Gunther, Bernadette A.
Hall, Avis A.
Hanby, Charles K.
Hannon, Martin
Hardin, Ronald Jr.
Harik, Nada
Harper, Steven C.
Harris, Daniel
Harris, Dehra A.
Harris, John E.
Harris, Julie A.
Harton, Timothy
Haynes, Katherine A.
Hearyman, Marty W.
Hemiksen, John
Hillis, Thomas M.
Hinton, Emily B.
Hinton, Thomas W.
Hoang, Thuy T.
Hogan, W. McCall Jr.
Holder, Devon L.
Holland, Cheryl
Holt, Brent E.
Hoover, Melanie D.
Hord, Marion E.
Horras, Randy J.
Hoskyn, Jerri L.
Howard, Charles E.
Howard, Stephanie J.
Howe, Wilson
Hults, Christopher M.
Hungarland, John D.
Jackson, Edward L.
Jackson, Kevin T.
Jackson, Matthew P.
Jarvis, Robert M.
Jennings, Bryan T.
Johnson, David G.
Johnson, Larry A. Jr.
Johnston, Alan C.
Johnston, Carol L.
Jones, Chrystal D.
Kagmmerling, Kristin
Kaler, Ronald J.
Keith, Rita J.
Kellar, Jeffrey D.
Keller, David E.
Kelly, Owen L.
Kerr, Kirsten S.
Kinneman, Kay L.
Klutts, James S.
Knox, Christopher G.
Knox, Micheal
Koehler, Kevin R.
Koury, Jadd W.
Kowalski, Magda U.
Krepps, Angela
Krepps, Brett
Kueter, Daniel B.
Volume 93, Number 7 - December 1996
373
Kueter, Joseph C.
La Croix, Michelle L.
Lam, Khim K.
Lassieur, Susanne M.
Lawrence, George S.
Lawson, Yolanda R.
Layton, Ann D.
LeDay, Romona
Lewis, Barrett D.
Lewis, Bruce
Liebersbach, Brian F.
Linsky, Russell A.
Logsdon, Todd W.
Lowery, John
Lu, Ellen
Luelf, Claire J.
Major, Victoria E.
Mallard, Gregory W.
Marks, Sonya D.
Marlin, April R.
Marotte, Jeff B.
Martin, Amy J.
Martin, Lisa R
Martine, Andrew R.
Matlock, Rhonda J.
McCallum, Sanford B.
McClain, Charles M. Ill
McCollum, N. Jill
McCourtney, Bill R. II
McDaniel, Lori L.
McDonald, Rodney K.
McDonnell, Bryan D.
McFarlane, Adrienne C.
McKinney, Vanessa L.
McMasters, Joel W.
McNiece, Karen L.
Mcgee-Reed, Ivy V
Meads, Anthony
Mehta, Rohit
Mendelson, Jeri
Meyer, Brian E.
Milligan, Joel
Mitchell, Trey
Moore, Troy G.
Morehead, Kristen N.
Morris, Kellie A.
Moss, Mark
Myers, Janette E.
Nehus, Ezechiel R.
Nelson, Elizabeth B.
Netherland, Clinton
Newcity, Marshall J.
Newland, Katherine D.
Newman, Adam G.
Niswanger, Melissa Q.
Noel, Stacey W.
Nolen, Michael
Norcross, Jonathan G.
Norris, Brian B.
Nor s worthy, Twyla
Nowell, Becky A.
Nwokedi, Emmanuel
O'Neal, Keane T
Oberste, David J.
Oglesby, Jimmy E.
Orender, J. Micheal
Ortiz, David D.
Osborne, Rebecca L.
Owens, R. Brian
Ozment, Dennis W.
Pafford, Michael B.
Pappas, Paul H.
Pappas, Pui Fun W.
Park, Jong C.
Parker, Jason D.
Parmley, Patricia E.
Patel, Ajay S.
Peebles, Jody W.
Peng, Edwin H.
Petty, Corwin D.
Phillips, Kristina M.
Pillow, Gill G.
Pillow, James H.
Pinchback, Michael E.
Price, Angela M.
Priest, Dean B. Jr.
Quevillon, Melissa N.
Reardon, Ruth A.
Reding, Eric L.
Reynolds, Tara P.
Rhodes, Ramona
Roberts, Kimberly A.
Roberts, Rusty L. Jr.
Robertson, Jonathon C.
Robinson, Lonnie S.
Rodgers, Chad T.
Rodgers, Michelle
Rose, Joseph G.
Ross, Ashley S. Ill
Ross, Douglas B.
Rowe, Tracy L.
Russell, Brian
Sadler, Jennifer M.
Sadler, Philip K.
Sauer, Kenneth M.
Sayre, R. Blake
Schach, Christopher P.
Scheer, Blake
Scherer, James G.
Schluterman, Keith O.
Schmid, John J.
Schmidt, Richard
Schmucker, Tracey A.
Schneider, Daniel L.
Schneider, Michael G.
Scott, Mitzi C.
Scott, William P.
Scruggs, Jennifer
Sharaf, Huda F.
Sharaf, Mai F.
Shearer, Helen M.
Sheng, Kai
Shermer, Susanna E.
Sherwood, Chad L.
Short, Walter
Shrestha, Shraddha S.
Simpson, Brian R.
Simpson, Christopher
Sims, LaRhonda
Skinner, Jason
Smith, Caroline C.
Smith, David L.
Smith, James H.
Smith-Foley, Stacy
Sneed, Thomas B.
Sorrels, Christopher W.
Spann, Aaron M.
Speer, Christine E.
Staggs, Amy E.
Staggs, Susan E.
Staley, Kelly
Stallcup, Tory L.
Steinert, Dejka
Steingraber, Kristin
Stennett, Melissa D.
Stern, Thomas P.
Stinnett, Jason M.
Stockburger, John S.
Stockdale, Donovan R.
Storm, Elizabeth A.
Stout, Eric C.
Stow, Glenn C.
Strother, Megan K.
Suffridge, Phillip J.
Swindle, David R.
Taylor, Jacqueline S.
Thomas, Wesley C.
Tilley, James B.
Turner, Jennifer M.
Turner, Marisa A.
Turner, Shannon R.
Tyler, Lisa N.
VanHook, Robert T.
Vogler, Carolyn E.
Wade, James E.
Walker, Kimberly A.
Walker, Randy
Wallace, Bradley A.
Wang-Gillam, Andrea
Warner, Justin D.
Wells, Michael J.
West, Brian J.
West, Margaret
White, Aaron E.
White, Richard A.
Wiedower, Amy C.
Wilkins, Benjamin T.
Williams, Mark C.
Williams, Veronica
Williams, W. Frank
Williamson, Anthony P.
Wilson, John E.
Wilson, Robert B. Ill
Winkler, Jerry M.
Wise, James N.
Woods, Barbara
Woods, Cecolra L.
Woods, Jennifer L.
Woods, Mark A.
Workman, James L. Jr.
Wright, Benjamin C.
Wright, Lonnie B.
Zimmerman, Stacy
374
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas Medical Society... A statewide network united for the common good of the medical
profession... dedicated to preserving the high standards of medicine... sharing ideas, knowledge
and experience. Arkansas Medical Society... A statewide network united for the common good of
the medical profession... dedicated to preserving the high standards of medicine... sharing ideas,
knowledge and experience. Arkansas Medical Society... A statewide network united for the com-
mon good of the medical profession... dedicated to preserving the high standards of
medicine... sharing ideas, knowledge and experience. Arkansas Medical Society... A statewide
network united for the common good of the medical profession.. .dedicated to preserving the
high standards of medicine... sharing ideas, knowledge and experience. Arkansas Medical
Society... A statewide network united for the common good of the medical profession... dedicated
to preserving the high standards of medicine. ..sharing ideas, knowledge and experience. Arkan-
sas Medical Society... A statewide network united for the common good of the medical
profession... dedicated to preserving tfifMgft standards pf medicine... sharing ideas, knowledge
and experience. Arkansas Med(p<d '0bWety'...A statewfde^0fwjork united for the common good of
the medical profession... d^dip^edto ppe0f^]pgdKfM^h, stdpd^^s of medicine... sharing ideas,
knowledge and experien(^yf^1cansps hd<^dffalSoci^ty.i.A "slqtewide network united for the com-
mon good of the med^^ pr'pfess'tfp/ ^'dedicated W the high standards of
medicine. ..sharing idcpf^^ kn(^wledg^dnd^p0ience. Apkanst^\Mdi^lcal Society... A statewide
network united for i^e ppm^pn gfod of thC/dli^fal prdfession\^..dpdlc£ited to preserving the
high standards of r^djcirj^.^^§i(tpg id^a0j^l^^ledge, dpd experience. Arkansas Medical
Society... A statewide^^^wOp^^^dedifor the c(pnmdn good-of the jpfdical profession... dedicated
to preserving the hVgfi i^gsj^khpwledge and experience. Ar-
kansas Medical Sodip^^..As^
profession...
and experience.
V
1h0pjomif^h good of the medical
/ine./.smring ideas, knowledge
_ _ ^ 'iite^Mp ^hp^/fk ui^0 for the common good of
the medical profession...'^^^c^f^kj^^^k^^mg the hi fkpf^dafdA^ medicine... sharing ideas,
knowledge and experience. Socmpr^ stqp0^^network united for the com-
mon good of the medicarpkffkssion...dedw^ to pre^pfving the high standards of
medicine... sharing ideas, knowled^dn^^^^^iMl Arkansas Medical Society... A statewide
network united for the common good^^^fi^e/m^ipM^p^rofession... dedicated to preserving the
high standards of medicine... sharing ideas, knowledge and experience. Arkansas Medical
Society... A statewide network united for the common good of the medical profession... dedicated
to preserving the high standards of medicine... sharing ideas, knowledge and experience. Ar-
kansas Medical Society... A statewide network united for the common good of the medical
profession... dedicated to preserving the high standards of medicine... sharing ideas, knowledge
and experience. Arkansas Medical Society... A statewide network united for the common good of
the medical profession... dedicated to preserving the high standards of medicine... sharing ideas,
knowledge and experience. Arkansas Medical Society... A statewide network united for the com-
mon good of the medical profession... dedicated to preserving the high standards of
medicine... sharing ideas, knowledge and experience. Arkansas Medical Society... A statewide
network united for the common good of the medical profession... dedicated to preserving the
high standards of medicine... sharing ideas, knowledge and experience. Arkansas Medical
Society... A statewide network united for the common good of the medical profession... dedicated
Volume 93, Number 7 - December 1996
375
Information for Authors
Advertisers Index
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AMS Benefits inside back
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Consumer Quote USA 343
Freemyer Collection System 328
Medical Practice Consultants, Inc 332
Riverside Motors, Inc 323
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory 324
Strategic Marketing
State Volunteer Mutual Insurance Company 314
The Maryland Group
Southwest Capital Management 321
Marion Kahn Communications, Inc.
U.S. Air Force 347
BJK&E Specialized Advertising
U.S. Air Force Reserve 313
HMS Partners, Inc.
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MEDICAUBOCIETY
Volume 93 Number 8
January 1997
HEAIW SCrENCES UBR/WY
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integrity, superior service record and flexible leasing plans . Volume
buying power gives Autoflex the edge over other companies and brings
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Words we still live by at State Volunteer Mutual (SVMIC). As a
physician owned and operated liability insurance provider, we
have a compelling interest in the continuing education of doctors.
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E S
V
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Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE
David Wroten
PRESIDENT
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
Obstetrics/Gynecology
Internal Medicine
Surgery
Family Practice
UAMS
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
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President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
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Secretary
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Treasurer
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Copyright 1997 by the Arkansas Medical Society.
Volume 93 Number 8
January 1997
CONTENTS
FEATURES
380
Physician Practice Evaluations - Do the Exams Never Stop?
Jerry Byrum, M.D.
383
Medicine in the News
Health Care Access Foundation Update
January Declared JNational Volunteer Blood Donor Month
Booklet Available on Chronic Fatigue Syndrome
AMA’s Superhero Joins Battle Against Tobacco
Disciplinary Action Bulletin - Arkansas State Board of Nursing
389
New Member Profile
Malek S. Karassi, M.D.
391
Legislative Outlook
Z. Lynn Zeno
392
Legislative Issues Listed
394
Legislator Information List
395
Tribute to a Political Leader - W. Payton Kolb, M.D.
396
Minutes of the AMS House of Delegates Fall 1996 Meeting
397
1997 AMS "Doctor of the Day" Program Calendar
402
The Patient's Right to Know - Full Disclosure Laws are
Necessary for Patients and Physicians
John Troupe, M.D.
404
Arkansas Physicians in the AMA - Your Representatives to
Medicine's Strongest Voice
James M. Kolb, Jr., M.D.
407
Hazards of Heparin
Loss Prevention
J. Kelley Avery, M.D.
417
Getting Acquainted with Ben N. Saltzman, M.D., Journal
Editorial Board Member
DEPARTMENTS
386
AMS Newsmakers
410
Cardiology Commentary & Update
412
State Health Watch
414
Arkansas HIV/AIDS Report
418
New Members
419
Radiological Case of the Month
421
In Memoriam
423
Things to Come
424
Keeping Up
Cover photo provided by the Arkansas Historic Preservation Program, an agency of the Department
of Arkansas Heritage.
Editorial
Physician Practice Evaluations - Do
the Exams Never Stop?
Jerry Byrum, M.D.*
I would like to relate two experiences in the realm
of practice evaluation that I've had this year that have
caused me to reflect on the profession of medicine. A
professor once said, that even though one finished
school, the process of examination of one's performance
would never stop. I have come to believe him.
The first experience is that of re-certification of
my pediatric board exam. Mine was one of the first
classes of residents who after successfully completing
the board exam of the American Board of Pediatrics
were issued a time-limited certificate of 7 years. All
previous successful board candidates had been issued
a lifetime certificate which is still in effect. This policy
change did not seem fair to me, particularly in the
light of the $1,055 price tag of the repeat exams and
the inordinate amount of time needed to study for
and then take the test. If one just placed a value of
$100 per hour on the forty plus hours it takes to com-
plete the exam and added the fee for the exam, the
cost is in excess of $5,000 every seven years not to
mention study time. I must adrhit that at the time I
took the initial exam in 1989, I had no intention of
repeating the process. However, over the ensuing
years, I noticed that hospitals, insurance companies
and even my patients were quite interested if I was
"board certified." My anger at this process of
re-certification grew over these years until finally, it
was time to take the exam this year (1996).
The exam for pediatric board re-certification is ad-
ministered by computer at home in an open book fash-
ion on the honor system. The components of the exam
are knowledge, diagnosis and management questions
which are given in separate tests. A passing score on
each of the three components yields re-certification.
I was not the only pediatrician upset about taking
this test. There were many letters and editorials writ-
ten about this process over the years. I intentionally
waited as long as possible to take the test before my
certification lapsed because I felt that there had to be
problems with the new methodology of administering
the test. There were in fact these problems. Because of
the tremendous time involved, the number of test
questions was shortened after several doctors com-
plained about its length. The records review part of
the test was deleted.
* Dr. Byrum is a Pediatrician with the All For Kids Pediatric
Clinic in Little Rock. He is a member of the editorial board
for The Joiirml of the Arkansas Medical Society.
I decided to pose this question to many of my
closest patients. "Do you care if your doctor is board
certified?" I asked my patients to please not confuse
the issue of continuing medical education with
re-certification. I am a believer in keeping up with new
developments in the field and told them so. This was
an issue of testing my competence to practice medi-
cine with test questions on a computer. Was this a
valid measurement of my competency? I was a bit
surprised to find out that not only did my patients
care about this certification, but they felt it was a mea-
surable sign of quality care and was in fact, expected
of me. After I heard this same response multiple times,
I sent in my application with $1,055.
What happened next was a surprise. On the ini-
tial test in board certification in 1989, there had been a
lot of questions on the test which I would describe as
"meaningless minutia" which had little bearing in my
opinion on the practice of general pediatrics. At that
time however, I had expected that kind of test and
had prepared over the three years of residency for it. I
knew every syndrome, metabolic pathway, anatomic
subtlety and rare disease that my mind could hold in
temporary storage. I passed.
In pediatric practice however, minutia is
de-emphasized and common things are emphasized.
One of my favorite sayings is "common things occur
commonly." Not that doctors in practice don't know
rare diseases or rare facts, many do. But for me to
remember minute details of non-clinical information,
would be impossible without intensive study which I
was reluctant to do. I had long since forgotten how
many nanometers there are in striated muscle period-
icity. This kind of information wasn't going to benefit
my patients. Also in practice, patients present with
complaints and symptoms, not diagnoses. It takes a
good doctor to take complaints and symptoms and
arrive at a diagnosis. How was the American Board of
Pediatrics going to check that?
Instead of studying for the test, I just took it, cold.
To my genuine surprise, the test was actually a plea-
sure to take. I found myself saying over and over again,
"I have been here." The questions were clinical in na-
ture and dealt with knowledge, management and di-
agnosis of the pediatric problems which I deal with
every day. Rare diseases were mentioned on the test,
but not in a way that was unlike what we see in prac-
tice. In fact, the Board even did a good job of present-
380
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
ing signs and symptoms and having the doctor arrive
at a diagnosis. I felt it was a good exercise.
Don't get me wrong, it still took an equivalent of
one week of work to complete the test. The cost was
still $1,055, a lot of money. But the process was a posi-
tive one in that I felt good about the job I'm doing for
my patients. After the test, I even placed the term
"Fellow, American Academy of Pediatrics, re-certified
1996" on my business card. Hey, you need to get some-
thing for all this trouble. So, hurdle number one of the
1996 evaluations was behind me, even though I was a
bit tired, poorer financially, and had 40 hours of effort
into the process. Please keep in mind that no continu-
ing education credit was gained for this investment of
money and time. That will require 40 to 60 more hours
and $2,000 more dollars.
The next evaluation of my professional practice
that I want to discuss began this fall when a local HMO
implemented an economic credentialing program. The
program tied reimbursement rates and even participa-
tion in the plan to what they called "Quality Index
Summary." As it turns out, the Quality Index Sum-
mary, or QIS score for short, is a compilation of com-
puter scores for various economic trends in one's prac-
tice. These trends are determined by analyzing claims
data for the members of the plan which the physician
has generated. There are multiple computer programs
which generate this data. Data on cost is presented in
several formats, such as average cost per patient, ac-
tual cost per patient, cost per claim, and claims per
patient. The various programs analyze the data just a
little differently. Drug utilization data is presented such
as cost per member and number of prescriptions per
member. The most frequent prescriptions written with
their corresponding cost is presented. Comments are
made to the appropriateness of the use of these drugs
without chart review. Hospitalization rates with length
of stay are presented. Of most importance is a presen-
tation of adjusted cost per member per month. Cur-
rent Procedural Terminology coding and International
Classification of Diseases coding mismatches are pre-
sented. An example of this is CPT code number 92567,
tympanometry with the ICD9 code 477.9, allergic rhini-
tis. The code for allergic rhinitis in their view does not
support the tympanometry procedural code. In addi-
tion, chart review data with comments on the appro-
priateness of diagnosis along with comments on the
legibility of the record is presented.
All this information is weighted, then evaluated
for each physician and finally summed up to yield an
efficiency quotient, the QIS score. This quotient is then
used to calculate the rate of reimbursement as a per-
centage of usual customary charges and whether or
not you will be allowed to continue to participate in
the plan. Because this process involves large numbers
of patients, diagnoses, codes, dollars spent, with re-
sulting statistics, and computer analyses, it is a com-
plex and time-consuming task to understand. Meet-
ings to discuss the findings are made. More meetings
to challenge the results are made. Corrections in data
errors and methodology are made. Hours of time are
consumed. Physician committees are recommended
to help the system become more accurate. More un-
compensated time is required in evaluating my practice.
Because a significant proportion of my patients
are covered in this plan, it is quite important that I be
successful in retaining these patients. Therefore, I co-
operate. But like the re-certification process, this evalu-
ation is intrusive, time-consuming and cumbersome.
After going through the two evaluations described
above this year, I then began to think about all the
other evaluations that take place regarding my prac-
tice. There are several others that I can mention. Of
course of utmost importance is that of my patients
who place their trust in me every day. Their very pres-
ence in my practice is the result of their evaluation of
me and to some extent the evaluations of others that
they hear. These evaluations are shared with other
people in the community and this combined body of
evaluations forms something called a "reputation." To
be successful, a doctor needs a good reputation.
Then there are the evaluations of the peers in my
practice, those three doctors whom I highly regard
and with whom I am honored to practice medicine on
a daily basis. This close working relationship was
brought about and continues because of evaluation of
our individual practices.
Next are the evaluations of peers outside the prac-
tice. This takes the form of referrals, professional rela-
tionships, committees, fellowships, societies and so
on. Then there are the hospital organizations where I
practice, with their attendant evaluations of compe-
tence, credentials, record keeping, drug utilization,
length of stay, cost, COBRA compliance, care path
compliance and so on. There is the Foundation of
Medical Care (Medicaid) whose evaluations of man-
agement frequently deny payments. Let us not forget
OSH A and CLIA evaluations. There are Medicare Peer
Review Organizations, the State Medical Board, at
times plaintiffs attorneys, and last but certainly not
least, other insurance companies. The list goes on and
on. I'm sure I've omitted several other forms of evalu-
ation that we face.
It seems to me that today's doctor is in the middle
of an economic and political crossfire of various groups
whose goals are very different and self-serving. I've
learned first hand this year that like it or not, evalua-
tions of my performance are a part of medicine today.
Unlike our predecessors who made their own rules,
other parties outside our control are requiring evalua-
tions that directly affect our ability to practice medi-
cine, our autonomy, our income and that spend our
precious free time on an uncompensated basis.
I wish I had a great paragraph to end this editorial
with, something to say that could be done to ease the
burden of evaluations that we face as doctors. But I
don't have a great paragraph to type here. All I can
say is that I'm just tired and a little bit angry.
Volume 93, Number 8 - January 1997
381
We can't guarantee that they'll follow in your footsteps, but we do know they need good health insurance
today. And so do you.
FINALLY, a health insurance plan designed to meet the needs of Arkansas' physicians. The ARKANSAS
MEDICAL SOCIETY ElEALTEl BENEFIT PROGRAM... offering a variety of benefit options including a choice
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Ask about our other services including Professional Overhead, Disability & Life Insurance
Medicine in the News
Health Care Access Foundation
As of December 1, 1996, the Arkansas Health Care
Access Foundation has provided free medical service
to 11,954 medically indigent persons, received 22,592
applications and enrolled 43,927 persons. This program
has 1,757 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
January Declared National Volunteer Blood
Donor Month
The American Association of Blood Banks,
American's Blood Centers and the American Red Cross
recently announced that President Bill Clinton has
proclaimed January 1997 as National Volunteer Blood
Donor Month to honor past and present blood donors
and encourage new donors.
Here are some interesting facts:
Every three seconds, someone needs blood. Ev-
ery minute, patients use more than 36 units of blood
or blood products. Every day, approximately 40,000
units of blood are used throughout the country.
About 14 million units (including approximately
one million autologous donations) of blood are do-
nated each year by approximately eight million volun-
teer blood donors. These units are transfused to as
many as four million patients per year. A unit of whole
blood is roughly equivalent to a pint. Adult males have
about 12 pints of blood in their circulatory systems,
and adult females have approximately nine pints. Each
unit is usually separated into multiple components,
which may be transfused to a number of different in-
dividuals. Up to four components can be derived from
one unit of blood.
On any given day, approximately 40,000 units of
red blood cells are needed. More than 23 million units
of blood components are transfused every year.
Less than 5 percent of healthy Americans eligible
to donate blood actually donate each year. According
to studies, the average donor is a college-educated
white male, between the ages of 30 and 50, who is
married and has an above-average income. However,
these statistics are changing, and women and minor-
ity groups are volunteering to donate in increasing
numbers. While persons 65 years and older compose
13 percent of the population, they use 25 percent of all
blood units transfused. Using current screening and
donation procedures, a growing number of blood banks
have found blood donation by the elderly to be safe
and practical.
The approximate distribution of blood types in the
U.S. population is as follows. Distribution may be dif-
ferent for specific racial and ethnic groups:
o
Rh-positive
38 percent
o
Rh-negative
7 percent
A
Rh-positive
34 percent
A
Rh-negative
6 percent
B
Rh-positive
9 percent
B
Rh-negative
2 percent
AB
Rh-positive
3 percent
AB
Rh-negative
1 percent
Booklet Available on Chronic Fatigue Syn-
drome (CFS)
The National Institute of Allergy and Infectious
Diseases (NIAID) has revised its popular booklet de-
veloped to inform the medical community about
chronic fatigue syndrome (CFS). Chronic Fatigue Syn-
drome: Information for Physicians can assist physicians
and other health professionals in developing a sup-
portive program of patient management that dispels
myths about CFS and its treatment, offers reassurance,
and helps patients and their families adjust to living
with this chronic illness. Free copies can be obtained
by writing to: CFS Booklet, NlAlD Office of Commu-
nications (31/7A50), 31 Center Drive, MSC 2520,
Bethesda, Maryland, 20892-2520. To order or down-
load the publication on-line, visit NIAID's home page
at http://www.niaid.nih.gov.
AMA's Superhero Joins Battle Against
Tobacco - Nation's Doctors Will Help Kids Smoke
Out the Tobacco Menagerie
"Look out camels, cowboys and penguins. Your
days of enticing kids to take up tobacco are coming to
an end," said Randolph D. Smoak, Jr., M.D., member
of the AMA Board of Trustees. That certainly is the
plan of the AMA which in November launched its
new cartoon superhero, "The Extinguisher," and his
mentor and creator, "Doctor Nola Know," two new
champions for America's kids in the fight against to-
bacco. Their mission is to educate and protect chil-
dren from the dangers of smoking. Together, they will
help kids wage their own "kid crusades" to "smoke
out" and "extinguish" the cigarette industry's adver-
tising and marketing campaigns toward America's
youth.
The super duo will be featured in a new AMA
nationwide public health campaign aimed at teaching
elementary school-age children about the dangers of
Volume 93, Number 8 - January 1997
383
smoking and nicotine addiction. Over the next year,
the AMA's Extinguisher and Dr. Know will appear at
anti-smoking events sponsored by kids, schools, and
anti- tobacco organizations.
The AMA will also be working with Scholastic News
to create anti-smoking educational materials featuring
the Extinguisher and Dr. Know for use in classrooms
across the country. Scholastic News is a current events
magazine for elementary school students distributed
to approximately four million children in 150,000 Ameri-
can classrooms. Kicking off the educational partner-
ship between the AMA and Scholastic News will be a
"Tobacco-Free Pledge Contest," in which kids will write
and sign a "tobacco-free pledge," explaining how they
plan to help in the fight against smoking and keep
their friends, schools and communities tobacco-free.
According to the cartoon narrative, the Extin-
guisher wasn't always a superhero. A short time ago,
he was a young man on the brink of death. His dis-
eased lungs had been so weakened by tobacco that
desperate measures were needed to save him. A smart,
savvy physician. Dr. Know, not only brought him back
to life, but turned him into a scientific wonder with
artificial lungs and "super powers," including increased
brain power and special heat-seeking devices able to
detect cigarettes from miles away. "I wanted to make
sure the Extinguisher was able to kick butts wherever
he finds them," Dr. Know said explaining her creation.
A study published in JAMA in 1991 showed that
children as young as six years old were as familiar
with "Old Joe Camel" as they were with Mickey Mouse,
and that such familiarity is a known risk factor for
smoking and tobacco addiction. "We know that every
day in the United States 3,000 young people begin to
smoke - that's more than a million new smokers each
year," said Dr. Smoak. "Each day our children are re-
placing the smokers who die prematurely from tobacco-
related diseases, the number one preventable cause of
death in the United States. This is a terrible travesty
that must end," vowed Dr. Smoak.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board office should be contacted. There-
fore, we routinely suggest this list be shared with the
appropriate supervisory personnel and recruiters in
your agency.
At the completion of the disciplinary period, the
nurse applies for reinstatement. Reinstatement is con-
tingent upon meeting conditions set forth by the Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY: November 6. 1996
*Ginger Kay Allen Davenport, RN #29756 (Ft. Smith)
Probation Non-Compliance; Probation extended
through 11/97
*Judee Anne Long, RN #31757 (Fayetteville) Volun-
tary Surrender
^William Hamilton, RN #29792 (Benton) Consent
Agreement; Probation - 2 years; Civil Penalty - $500
^Matthew Douglas Wallace, RN #44869 (Hot Springs)
Suspended - 5 years; Civil Penalty - $4,400
DISCIPLINARY: November 7, 1996
*James William Hall, RN #30366 (Cabot) Probation - 2
years; Civil Penalty - $250
“^Jackqueline Rennae Bryant Cschwend, RN #24957
(Marvell) Allowed to renew RN license; Suspended - 2
years; Civil Penalty - $500
^Patricia Lynn Bright Walker, LPN #24615 (Clenwood)
Allowed to renew LPN license; Suspended - 2 years;
Civil Penalty - $1,100
^Rebecca Jill Cramling Wells, RN #33205 (Paragould)
Suspended - 5 years
“^Cynthia Michelle Smith Konert, RN #29297 (Van
Buren) Probation non-compliance; probation extended
through 11/97; Civil Penalty - $250
*Sharon Ann Morris, RN #11056 (Springdale) Rein-
stated RN license with 1 year probation
^Barbara Lynn Coleman Cash, RN #24941 (Fayetteville)
Reinstated RN license with 1 year probation
LETTER OF REPRIMAND:
*Brenda Kay Willis Wisener, RN 44870 (Warren) 10/11/96
^Kathleen Lavonne Barlow Westman, RN 26007 (Hot
Springs) 10/11/96
*Beverly Kay Toddy McClung, LPN 32824 (Rector) 10/14/96
*Carol Elaine Cilley, LPN 13992 (Morrilton) 10/15/96
^Connie Marie Lummus, LPN 31711 (Texarkana) 10/15/96
*Tina Lynn Webb Hood, LPN 30082 (Malvern) 10/11/96
*Diana Lynn Camer Jarrett, LPN 26490 (Everton) 10/11/96
*Troy Robinson, LPN 31421 (Hot Springs) 10/14/96
*Darren Scott Smith, LPN 31453 (St. Joe) 10/15/96
*Tonya M. Long, RN 44346 (Wheatley) 10/15/96
*Mary Sue Pate Clemons, RN 44152 (Sparkman) 10/11/96
^Beverly Knight, RN 21778, RNP 973 (Little Rock) 10/14/96
*Darlene Love O'KeKe, LPN 30206 (Little Rock) 10/15/96
’^Sharon Kaye Meeks Mays, LPN 27997 (Pine Bluff) 10/15/96
^Timothy Dean McAfee, LPN 32351 (Caraway) 10/30/96
384 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
OFF PROBATION:
*Kimberly Ann Green, RN 30356 (Rogers) 9/17/96
*Lisa Woodward Jones, LPN 23255 (Greenbrier) 10/29/96
*Mary Della Roark Freeman, LPTN 768 (Sparkman)
10/9/96
*Chris Larimer, LPN 28980 (Ft. Smith) 10/7/96
^Virginia June (Gaither) Howard, RN 40617 (Nash, TX)
10/9/96
REINSTATEMENT:
’'Michael Day Aylett, RN 37777/LPN 20942 (Nashville)
9/23/96 (Probation to continue through 5/97)
’'Carolyn Jean Harding Sebby, RN 30585 (Bull Shoals)
11/7/96
ALERT:
If you have employed the following nurses or have
any knowledge of their whereabouts, please notify the
Board of Nursing at (501) 686-2700.
’'Donna Kay DeVore, RN 31613
’'Debra Bussiere, RN 51249
’'Leslie Beth Hohimer George, RN 51696
’'David Rowland, RN 49165
Emergency Medicine Opportunities
Full-Time Opportunities available in:
Van Buren
Crawford Memorial Hospital is a modern, 103-
bed facility with an armual ED volume of 14,000.
WE OFFER: Competitive Remuneration,
Occurrence Maipractice & Flexible Hours
For more information on these and other
opportunities in Arkansas please contact:
Tom Kubiak 800-325-2716 or
FAX CV to Tom at 314-919-8920.
CORRECTION NOTICE:
In the November 1996 issue of The Journal of
the Arkansas Medical Society, on page 299, in
the New Member section, under Little Rock, the
name of Doctor Charles Robert Feild was spelled
incorrectly. The correct spelling is as it appears
here. The Journal regrets this error.
Some simple logic. . .
If iVs
green,
shouldn't
it be
growing
Is your big name
investment company
giving your money
the attention
that it needs to grow?
If not call us.
SOUTHWEST CAPITAL MANAGEMENT, INC.
REGISTERED INVESTMENT ADVISOR
Fee based • $100,000 minimum
Thomas N. Schallhorn, President
105 West Capitol Avenue, Suite 101
Little Rock, AR 72201-5732
501.374.1119 • 1.800.333.1230
Specialists in the accumulation
and preservation of wealth
AMS Newsmakers
Dr. William D. White recently received a certifi-
cate from the American College of Cardiology in rec-
ognition of meeting or exceeding a skill level consid-
ered adequate for independent interpretation of the
wide range of electrocardiographic patterns encoun-
tered in hospitals and outpatient medical practice.
Dr. M.M. Zufari, a vascular and general surgeon
in Fort Smith, attended the annual conference on Ad-
vanced Interventional Techniques for Peripheral Vas-
cular Disease in Chicago, Illinois, in September. Led
by world renown physicians, Dr. Zurfari participated
with other attendees in live patient demonstrations,
observing techniques of managing disorders such as
blood clots, renal artery stenosis and acute stroke.
With nearly 5,000 other family physicians from
across the country, Drs. Edward A. Gresham and
Benjamin L. Walsh, both of Crossett, attended the
American Academy of Family Physicians' Annual Sci-
entific Assembly in New Orleans, Louisiana, in October.
Drs. Darrell Speed, a radiology oncologist; Doug
Kerin, radiologist; Stan Teeter, primary care physi-
cian; and Mike Bell, surgeon, all of Russellville, were
among other panelists for a question-and-answer fo-
rum during a breast cancer seminar at Saint Mary's
Regional Medical Center in October. About 100 women
attended the seminar.
The Physician's Recognition Award is awarded
each month to physicians who have completed accept-
able programs of continuing education. Recipients for
October 1996 are; Olaniyi Osofisan, of Van Buren, and
Dallie Ricca, of Jonesboro.
Send your accomplishments and photo for
consideration in AMS Newsmakers to:
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
'^Icome Back Dk Roman
We are proud to announce that Dr. Juan J. Roman has
returned to UAMS Medical Center as a Gynecologic
Oncologist and professor. From 1970-1976, Dr. Roman was on
the faculty at UAMS. During the last 20 years he has been in
private practice and has served in various leadership roles at
St. Vincent Infirmary Medical Center including chief of
gynecology.
UAMS Medical Center is the state’s only member of the
Gynecologic Oncology Group, a National Cancer Institute-
funded cooperative program that arranges clinical trials for
new treatments for women with gynecologic cancers. With
the addition of Dr. Roman, UAMS Medical Center now has
three of the four gynecologic
oncologists in the state on its staff.
To refer patients to Dr. Roman or to
one of his colleagues, please call
686-8000 or 1 -800-94 2-UAMS.
UAMS
MEDICAL
CENTER
World Class Care
University of Arkansas for Medical Sciences • 4301 West Markham • Little Rock,AR 72205
386
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Medicare Post Pay Review Audits
Effective January 1 , 1997, the federal government will step up their efforts to identify
CODING VIOLATIONS AND CONSIDER FRAUD AND ABUSE CHARGES AGAINST PHYSICIANS.
It IS THE DOCTOR’S RESPONSIBILITY TO KNOW — OR LEARN — ACCURACY.
Can your office manager profile your practice?
(Good idea to ask that question now.)
Ever been audited by Medicare/Medicaid?
!!!!!!!!!NOT FUN!!!!!!!!!!
$900,000 in 30 days, (could you?)
Let us “Profile” your practice
and you will avoid the possibility of the above problems.
• We will show you how your practice compares to your peer group.
• Verify your level of service coding process.
• Insure that you are not violating “volume screens.”
• Determine your ranking among your peer group specialty.
Call our Senior Consultant. Donald Smith, today.
He worked for Arkansas BCBS & Medicare for five years.
Achieve EXCELLENCE through Experience, Knowledge and Accuracy.
Join the many clients of Medical Practice Consultants, Inc. and enjoy their success.
Call MPC, Inc. 501-972-1200 TODAY for immediate assistance.
Medical Practice Consultants, Inc.
1400 Fairway Drive • Jonesboro, Arkansas 72401 • 501-972-1200
Donald B. Smith, Senior Consultant • Member, MGMA
Thomas L. Stickel, Associate Consultant
C. Scott Winningham, Marketing Consultant
Here's Our Agenda
It’s simple. It’s straightforward. And it represents the future of
medicine. The American Medical Association presented to the
Republican and Democratic leadership this agenda for the upcom-
ing 105th Congress. Your AMA membership strengthens our voice
in support of physicians and their patients. . . and will enhance our
efforts to turn these goals into reality.
• Patient Protections Above all, preserve the ability of physicians to
act as advocates for their individual patients. Do not allow insurers
to “gag” physicians or withhold medically necessaiy treatments
from their patients.
• Medicare Reform Make the Medicare program solvent. Expand
patient choice of plans. Allow future growth rates that cover
patients needs. Retain special protection for the vulnerable
and elderly.
• Medical Education and Research Continue to support medical
education and research so we can find cures for killers such as
AIDS and cancer.
• Public Health Problems Expand prevention and treatment
programs to combat AIDS, drug abuse, smoking and violence.
These problems cost billions of dollars and millions of lives.
• Liability Reform Enact meaningful liability reform to ensure fair
compensation to patients with legitimate claims while eliminating
excessive malpractice awards that lead to defensive medicine.
Join or renew your membership in the AMA today —
call 800 AMA-321 1
American Medical Association
Physicians dedicated to the health of America
Years cf Caring for the Country
1847 • 1997
New Profile
di
Malek S. Karassi, M.D.
PROFESSIONAL INFORMATION
Specialty: Internal Medicine - Endocrinology
Years in Practice: one
Office: Decatur
Medical School: Aleppo University, Syria, 1989, and Chicago Medical School, 1992
Residency: UAMS, 1994
Fellowship: University of California, 1995
Volunteer work: Aleppo University, Al-Razi Hospital ER, and as a medical student at Al-Watani
Hospital ER and in rural areas in Syria three times a week
Honors! Awards: Graduated 11th out of a class of 14,000
PERSONAL INFORMATION
Date/Place of Birth: June 6, 1964 in Syria
Spouse: Najwa Karassi, housewife
Children: daughters, Tasneem, three years old and Bayan, four months old
Hobbies: Reading (science books), watching sports, playing ping-pong
THOUGHTS & OTHER INFORMATION
If I had a different job, Fd be: a mathematician
Worst habit: Reading (it upsets my wife!)
Best habit: Reading (I enjoy it!)
Favorite junk food: Burger King Double Whopper
I most value: My wife and children
People who knew me in medical school, thought I was: caring and hard working with a
strong memory
The turning point of my life was when: I was accepted into medical school on a scholarship
Favorite vacation spot: Home with family
One goal I am proud to have reached: Having a stable family
Favorite Childhood Memory: When I got my first bike
When I was a child, I wanted to grow up to be: An architectural engineer
One of my pet peeves: I don't have any
First job: Selling clothes in carnivals (in Syria)
Worst job: none
One word to sum me up: Life (I like life)
My life philosophy: Be happy, realistic and give people chances
If you would like to appear in New Member
Profile or Member Profile, contact Tina Wade
at AMS at (50 1 ) 224-8967 or 1 -800-542- 1058.
Volume 93, Number 8 - January 1997
389
Even parked, it’s unparalleled
The S-Class. Carefully sculpted lines. Meticulous details inside and out. No wonder few cars compare.
Mercedes-Benz
Riverside Motors, Inc.
1403 Rebsamen Park Rd./Little Rock, AR 72202
666-9457 & 1-800-457-6226
©1995 Authorized Mercedes-Benz Dealers
Legislative
OUTLOOK
Z. Lynn Zeno, AMS Director of Governmental Affairs
No one knows
more about
health care than
physicians.
Let your voice be
heard. The 8T^
Session of the
Arkansas General
Assembly begins
on Monday,
January 13, 1997.
New Year Brings New Challenges
The New Year will bring new challenges as the 81®‘ Session of the Arkansas General
Assembly begins on Monday, January 13, 1997.
A plethora of health related legislation is expected as third party payors seek greater
control of medicine; allied health providers attempt to expand their scopes of practice;
state government tries to roll back Medicaid funding; another attempt will be made to
tax tobacco; and the list goes on and on and on...
The Arkansas Medical Society House of Delegates met October 17, 1996, in Hot
Springs at the annual fall meeting and took official positions on twenty-five important
issues that have already been identified for debate in the upcoming legislative session.
Following this article is a listing with a brief description of the proposed legislation by
various classification and AMS's position.
How Can You Help?
Although medical society representation at the Capitol is a vital component to
successful lobbying, the keystone to any legislative success is support from the
"grassroots."
When considering various legislative proposals, lawmakers want to know the views
of their constituents. They are always impressed when a physician takes the time away
from their busy schedule to call upon them. No one knows more about health care
than physicians!
Contacting Your Legislators
The AMS will update you on important issues throughout the legislative session
via the weekly Legislative Update and other special bulletins. If you need additional
information before contacting your legislators call the Society office and we will brief
you on the status of legislation. Your visit will be more effective with complete knowl-
edge of the issues.
Occasionally, time is of the essence and you can call your legislators at the State
Capitol. Generally, there is time to contact them locally, on the weekends, in their
home districts. Do not hesitate to call them at home, they expect it; it goes with the territory.
If you are in Little Rock (for the out-of-towners), you may want to visit your legis-
lators at the State Capitol. Legislators will welcome your visit, but time may be limited
with the rush of committee meetings, hearings, etc. that transpire during the session.
Stay in touch with your legislators. Let them know your interest is sincere and that
they can contact you if they need more information on a medical issue. Please alert
your office staff that if a Senator or Representative calls... you need to be interrupted.
A list of 1997 legislators with their addresses and phone numbers is printed in this
issue of The Journal for your convenience. This list will also be printed on the reverse
side of your weekly Legislative Update bulletin.
Volume 93, Number 8 - January 1997
391
ISSUE POSITION
ALLIED HEALTH CARE PROVIDERS:
Medical Assistants
A bill to define the responsibilities and authorize
the use of medical assistants by physicians
Support
Certified Registered Nurse Anesthetists
A bill to allow Certified Registered Nurse Anesthetists to
practice independently without physician supervision
Oppose
Optometrist Prescribing
A bill to expand optometry scope of practice to
include full prescribing privileges and the use of lasers
Oppose
Oral Surgeons
A bill expanding the dentist scope of practice to
allow oral surgeons to perform facial reconstruction
Oppose
Podiatrist Hospital Privileges
A bill to prohibit discrimination against podiatrists
in regard to hospital privileges
Oppose
Acupuncturist Licensing
A bill to establish licensure for acupuncturists
LEGAL ISSUES:
Oppose
Comprehensive Tort Reform
A bill addressing a comprehensive package of legal
reforms to include: joint and several liability, collateral
source, product liability, limits on punitive damages,
limits on contingency fees and structured settlements
Support
Third-Party Payor Liability
A bill to place liability on insurance companies for patients
injured as a result of a decision by third-party payors
Support
Civil Immunity for Emergency! Disaster Care
A bill to provide civil immunity for lawyers and physicians who
Support
provide uncompensated care in conjunction with emergency or disaster relatec
care
Opening of Peer Review Records
A bill opening up hospital or clinic peer review proceedings
to discovery in medical malpractice proceedings
MANAGED CARE INSURANCE ISSUES:
Oppose
Patient Protection Act II
A Comprehensive bill regarding managed care including: disclosure
of financial incentives for providers not to treat; disclosure of
provider selection and de-selection criteria; establishment of appeal
and grievance procedures; elimination of "gag" rules in contracts; and
drive through delivery standards
Support
392
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
ISSUE POSITION
Medical Savings Accounts
A bill authorizing and establishing state guidelines
for medical savings accounts
.... Support
Workers' Compensation Reform
A comprehensive bill of changes in workers' comp law
....To be determined
Medical Records
A bill to standardize medical record fees at 25 cents per page
.... Oppose
Mental Health Parity
A bill to require third-party payors to reimburse treatment of
mental health coverage on the same basis as other health care coverage
.... Support
STATE AGENCIES REGULATORY ISSUES:
Medicaid Reform/ Funding
A comprehensive bill regarding changes in the State Medicaid Program
....To be determined
Licensing of Nonresident Physicians
A bill to require Arkansas licensure for out-of-state
physicians providing radiology and pathology services
.... Support
Intractable Pain
A bill to define intractable pain and provide protection
for physician prescribing
....To be determined
Criminal Record Checks
A bill to require criminal record checks for all health
care providers in treatment facilities
.... Support
with amendments
Physician Data Bank
A bill opening up the physician data bank (credentials,
malpractice claims, etc.) to public inspection
.... Oppose
PUBLIC HEALTH:
Bottle Rockets
A bill to prohibit sale and use of bottle rockets
.... Support
Tobacco Tax for Breast Cancer
A bill imposing a two-and-one-half cent per pack tobacco tax with
revenues dedicated to breast cancer research, treatment and education
....Support
AIDS Testing
A bill requiring AIDS test for pregnant women
.... Support
Motorcycle Helmet Law
A bill to repeal the helmet law requirement in Arkansas
.... Oppose
Volume 93, Number 8 - January 1997
393
MFKansas nouse or Kepreseniaiives
(1997-1998)
Representatives/Mailing Address/HomeTelephone
Honorable Jerry Allison, 26 CR 744, Jonesboro, 72401
Honorable Evelyn L. Ammons, PO Box 1005, Waldron, 72958-1005
Honorable Sam E. Angel II, PO Box 748, Lake Village, 71653-0748
Honorable Thomas G. “Tom” Baker, 124 Lawrence Road 532, Alicia, 72410
Honorable David L. Beatty, PO Box 640, Lewisville, 71845-0640
Honorable M. Dee Bennett, PhD, PO Box 17033, North Little Rock, 72117
Honorable Dave Bisbee, 14068 Pyramid Drive, Rogers, 72758-0116
Honorable Pat Bond, 717 Foxwood, Jacksonville, 72076
Honorable Michael D. Booker, PO Box 45154, Little Rock, 72214-0154
Honorable Shane Broadway, 201 S.E. 2nd, Bryant, 72022
Honorable Irma Hunter Brown, 1920 S. Summit Street, Little Rock, 72202
Honorable Randy Bryant, 14138 DeGraff Road, Rogers, 72756-8869
Honorable Ann H. Bush, PO Box 246, Blytheville, 72316-0246
Honorable John Paul Capps, PO Box 1488, Searcy, 72143-1488
Honorable David Choate, 709 N. Main Street, Beebe, 72012-2821
Honorable M. Olin Cook, 266 S. Enid Avenue, Russellville 72801-4534
Honorable Tom C. Courtway, PO Box 56, Conway, 72033-0056
Honorable Jack L. Critcher, PO Box 79, Grubbs, 72431-0079
Honorable Ernest Cunningham, 727 Columbia Street, Helena, 72342-2813
Honorable Armil O. Curran, 210 W. Main Street, Clarksville, 72830-3010
Honorable Michael K. Davis, 1 5232 Hwy. 90 West, Ravenden Springs, 72460
Honorable John H. Dawson, PO Box 336, Camden, 71701-0336
Honorable Gunner DeLay, 4200 Free Ferry Lane, Fort Smith, 72901
Honorable James G. Dietz, 4221 Richards Road, North Little Rock, 72117
Honorable Steve Faris, Route 2, Box 365, Malvern, 72104
Honorable Scott Ferguson, MD, 200 S. Rhodes, #B, West Memphis, 72301
Honorable Lisa Ferrell, 702 N. Van Buren, Little Rock, 72205-3660
Honorable Patrick H. Flanagin, 935 N. Washington, Forrest City, 72335
Honorable Billi Fletcher, 403 W. Palm Street, Lonoke, 72086-3445
Honorable George R. French, 190 Tracy Drive, Monticello, 71655
Honorable Charles Roger Fuqua, 3907 Lankford St., Springdale, 72762
Honorable Lloyd R. George, Route 1 East, Ola, 72853
Honorable Larry Goodwin, PO Box 129, Cave City, 72521-0129
Honorable Rita Hale, 123 Westport Point, Hot Springs, 71913
Honorable John Hall, 2429 Highway 348, Rudy, 72952-9401
Honorable Joe Harris Jr., PO Box 781, Osceola, 72370-0781
Honorable David C. Hausam, 1214 N.E. 10th, Bentonville, 72712
Honorable Jim Hendren, Route 1, Box 260, Sulphur Springs, 72768-9758
Honorable Bobby L. Hogue, PO Box 97, Jonesboro, 72403 SPEAKER
Honorable Barbara Horn, PO Box 64, Foreman, 71836-0064
Honorable Dianne Hudson, 104 Devon, Sherwood, 72120
Honorable Joe K. Hudson, PO Box 470, Mountain Home, 72653-0470
Honorable Jerry F. Hunton, 14221 Greasy Valley Rd., Prairie Grove, 72753
Honorable Marian Owens Ingram, PO Box 449, Warren, 71671-0449
Honorable Jimmy Jeffress, PO Box 1695, Crossett, 71635
Honorable Bob Johnson, PO Box 173, Bigelow, 72016-0173
Honorable Myra Jones, 5201 Country Club Boulevard, Little Rock, 72207
Honorable Douglas C. Kidd, PO Box 137, Benton, 72018-0137
Honorable Jim Lancaster, 43 Toler Road, Sheridan, 72150
Honorable Randy Laverty, PO Box 303, Jasper, 72641-0303
932-7960
637-2765
265-2346
886-6013
921-4219
945-7724
636-2516
982-8872
224-8988
847-7796
372-4140
451-8649
763-7224
268-8117
882-5743
968-4203
336- 9208
252-3592
338-6868
754-2447
869-2796
836-2270
782-4727
758- 6703
337- 7307
735-7098
663- 9350
633-2602
676-6634
367-2804
750-1107
489-5641
528-3721
525-1933
471-1543
563-8360
273-7050
298-3533
932-9752
542-6665
835-4107
425-9031
824-5254
226-5276
364-8291
759- 2001
664- 7775
315-1555
942-3481
446-5593
Honorable James C. “Jim” Luker, PO Box 216, Wynne, 72396-0216
Honorable Becky L. Lynn, PO Box 450, Heber Springs, 72543-0450
Honorable Ode Maddox, PO Box 128, Oden, 71961-0128
Honorable Sue Madison, 573 Rock Cliff Road, Fayetteville, 72701-3809
Honorable Jim Magnus, 10 Cimarron Valley Circle, Little Rock 72212
Honorable Percy Malone, 518 Clay Street, Arkadelphia, 71923-6024
Honorable Ben McGee, PO Box 240, Marion, 72364-0240
Honorable W.K. “Mac” McGehee Jr., PO Box 4106, Fort Smith, 72914
Honorable Bob McGinnis, 81 Highway 316, Marianna, 72360-8317
Honorable Louis M. McJunkin, PO Box 223, Springdale, 72765-0223
Honorable Jimmie Don McKissack, 3418 Hwy. 65 South, Pine Bluff, 71601
Honorable John E. Miller, PO Box 420, Melbourne, 72556-0420
Honorable Jim Milum, 607 Skyline Drive, Harrison, 72601
Honorable Joe Molinaro, 204 Amber Oaks Drive, Sherwood, 72120-2200
Honorable Ted E. Mullenix, 140 Riverside Road, Hot Springs, 71913-9576
Honorable Bobby G. Newman, PO Box 52, Smackover, 71762-0052
Honorable Wanda Northcutt, PO Box 350, Stuttgart, 72160-0350
Honorable PatG. Pappas, 2901 S. Willow, Pine Bluff, 71603-5061
Honorable Carolyn Pollan, 400 N. 8th Street, Fort Smith, 72901-2204
Honorable Billy Joe Purdom, Route 1, Box 135B, Yellville, 72687-9728
Honorable Jacqueline J. Roberts, PO Box 2075, Pine Bluff, 71613-2075
Honorable Sandra D. Rodgers, PO Box 595, Hope, 71802-0595
Honorable Roger L. Rohe, PO Box 136, Fox, 72051-0136
Honorable Charlotte T. Schexnayder, PO Box 220, Dumas, 71639-0220
Honorable Courtney Sheppard, PO Box 1132, El Dorado, 71730-1132
Honorable Martha A. Shoffner, PO Box 44, Newport, 72112
Honorable Richard Simmons, 1751 CR 508, Rector, 72461
Honorable Stephen M. Simon, 13 Bud Chuck Lane, Conway, 72032-9788
Honorable Judy S. Smith, PO Box 213, Camden, 71701-0213
Honorable Terry Smith, 181 Caroline Acres Road, Hot Springs, 71913
Honorable E. Ray Stalnaker, 11714 Arch Street Pike, Little Rock, 72206
Honorable Charles W. Stewart Jr., PO Box 1167, Fayetteville, 72702-1167
Honorable Larry R. Teague, PO Box 903, Nashville, 71852-0903
Honorable Edward “Ed” F. Thicksten, PO Box 2019, Alma, 72921-2019
Honorable Ted J. Thomas, 900 S. Shackleford, #300, Little Rock, 7221 1
Honorable Bobby Lee Trammell, 5213 Richardson Dr., Jonesboro, 72401
Honorable Stuart C. Vess, 6717 Pontiac Drive, North Little Rock, 72116
Honorable Wayne Wagner, PO Box 909, Manila, 72442-0909
Honorable Wilma Walker, PO Box 205, College Station, 72053-0205
Honorable D.R. “Buddy” Wallis, Route 5, Box 489, Malvern, 72104
Honorable Charles Whorton Jr., Route 5, Box 2242, Huntsville, 72740
Honorable Josetta E. Wilkins, 303 N. Maple Street, Pine Bluff, 71601
Honorable Ed Wilkinson, PO Box 610, Greenwood, 72936-0610
Honorable Frank J. Willems, 2921 Union Road, Paris, 72855-2282
Honorable Jimmie L. Wilson, 1738 Phillips County 438 Rd., Lexa, 72355
Honorable Jim Wood, Box 219, Highway 33 West, Tupelo, 72169
Honorable Tim Wooldridge, 100 College Drive, Paragould, 72450-9775
Honorable Greg Wren, 1404 Caldwell Street, Conway, 72032-5365
Honorable Dennis Young, PO Box 1835, Texarkana, 75504
District 52 - Vacant
Arkansas State Senate
(1997-1998)
Senators/Mailing Address/HomeTelephone
Honorable Jim Argue Jr., 5905 Forest Place, #210, Little Rock, 72207 224-8181
Honorable Mike Bearden, PO Box 1824, Blytheville, 72316 762-0714
Honorable Mike Beebe, 21 1 W. Arch Avenue, Searcy, 72143 268-9452
Honorable Steve Bell, 500 E. Main, Suite 208, Batesville, 72501 793-6232
Honorable Fay W. Boozman III, MD, 2901 Honeysuckle Ln., Rogers, 72758 636-1019
Honorable Jay Bradford, PO Box 8367, Pine Bluff, 7161 1 535-5549
Honorable John E. Brown, 17900 Ridgeway Drive, Siloam Springs, 72761 524-4667
Honorable Eugene “Bud” Canada, PO Box 2110, Hot Springs, 71914 525-3126
Honorable Wayne Dowd, PO Box 2631, Texarkana, 75504 PRO TEM 772-0525
Honorable Jean Edwards, 8607 Earl Chadick Road, Sherrill, 72152 766-4049
Honorable Mike Everett, 412 Broadway, Marked Tree, 72365 358-3560
Honorable Jonathan S. Fitch, Rural Route 1, Hindsville, 72738 789-2608
Honorable Allen Gordon, PO Box 558, Morrilton, 72110 354-2122
Honorable Bill Gwatney, PO Box 156, Jacksonville, 72076 982-4817
Honorable Morril H. Harriman Jr., 522 Main Street, Van Buren, 72956 474-0480
Honorable Jim Hill, 100 Center, Nashville, 71852 845-3273
Honorable Cliff Hoofman, PO Box 1 038, North Little Rock, 72115 758-9692
Honorable George Hopkins, PO Box 913, Malvern, 72104 337-4442
Honorable Gary D. Hunter, 145 Spring Lake Dr., Mountain Home, 72653
Honorable Peggy Jeffries, 1122 S. Waldron Road, #C, Fort Smith, 72903
Honorable Tom Kennedy, PO Box 2396, Russellville, 72801
Honorable Roy C. “Bill” Lewellen, PO Box 403, Marianna, 72360
Honorable Jodie Mahony II, 106 W. Main, #406, El Dorado, 71730
Honorable David R. Malone, PO Box 1048, Fayetteville, 72702
Honorable Gene Roebuck, PO Box 1696, Jonesboro, 72410
Honorable Mike Ross, PO Box 374, Prescott, 71857
Honorable Stanley Russ, PO Box 787, Conway, 72033
Honorable James C. Scott, 321 State Hwy. 15 North, Warren, 71671
Honorable Kevin Smith, 1609 Coker-Hampton Drive, Stuttgart, 72160
Honorable Mike Todd, 333 W. Court Street, Paragould, 72450
Honorable William L. Walker Jr., PO Box 1609, Little Rock, 72203
Honorable Bill Walters, PO Box 280, Greenwood, 72936
Honorable Doyle L. Webb, PO Box 1998, Benton, 72018
Honorable Nick Wilson, PO Box 525, Pocahontas, 72455
District 16 - Vacant
238- 222:
362- 9431
326- 432
442-299;
224-712*
246-717;
739-417'
452-5111
295-339'
751-041:
536-207:
368-715:
741-753:
834- 5581
767-536^
725-324:
673-842/
536-4195
782-646:
436-7735
536-172:
777-390/
363- 4545
382-525:
862-1543
523-3716
522-3204
796-8466
836-3946
525-0245
888-6724
442-6474
845-370E
632-4288
227-6684
932-4635
835- 6284
561-4601
490-0235
844-4895
232-5741
534-5852
996-4260
934-4213
827-6789
744-2266
239- 8763
327- 3506
773-4139
425-2220
452-4322
967-3461
295-6989
862-5950
442-0633
935-4014
887-5020
329-8186
226-5336
673-3422
239-2590
375-5275
996-4520
315-4266
892-8853
U.S. Congressional Correspondence:
Honorable Dale Bumpers, United States Senate, 229 Dirksen Senate Office Building, Washington, D.C. 20510 (202) 224-4843
Honorable Jay Dickey, U.S. House of Representatives, 230 Cannon House Office Building, Washington. D C. 20515
(202) 225-3772
Newly-elected US Senator Tim Hutchinson and US Representatives Marion Berry, Asa Hutchinson and Vic Snyder, MD have temporary offices at this time. To telephone Senator Hutchinson,
Congressmen Berry, Hutchinson or Snyder, dial the US Capitol Switchboard at 202-224-3121 . Ask the operator for the Senator or the Representative by name and state.
Tribute to
a Political Leader
W. Payton Kolb, M.D.
1919-1996
A champion for
mental health
issues and a
credible spokesman
in all other areas
of medicine, Dr.
W, Payton Kolb
leaves behind a
crevice impossible
to fill. He served
as AMS President
in 1977-1978
As I was writing the Legislative Outlook for this issue of The Jour-
nal, I was notified that Payton Kolb, M.D., was in serious condition at
Little Rock's Baptist Hospital. Before I completed the article. Dr. Kolb
passed away on Sunday, December 8, 1996.
I walked the marbled halls for 13 years prior to joining the Arkan-
sas Medical Society and Dr. Kolb was a fixture around the State Capi-
tol. As a psychiatrist he was, of course, a champion for mental health
issues and his reputation for honesty also made him a credible spokes-
man in aU other areas of medicine (he began his career in family practice).
In my nine years as lobbyist for the Medical Society, Dr. Kolb be-
came one of my closest friends and most trusted advisors. His institu-
tional and legislative memory was incredible. I also discovered that
his reputation extended from the halls of the State Capitol... to the
halls of the Nation's Capitol... to his state and national specialty
organizations... and to the American Medical Association.
I'm fortunate to have other doctors to advise me and to make the
Capitol rounds in Little Rock and Washington, DC, but Dr. Kolb's
absence from the political arena will leave a crevice that will be impos-
sible to fill.
Z. Lynn Zeno, AMS Director of Governmental Affairs
Volume 93, Number 8 - January 1997
395
Minutes of the
Arkansas Medical Society
House of Delegates
November 17, 1996
Dr. Anna Redman, Speaker of the House of Delegates,
called the meeting to order. Dr. John Crenshaw wel-
comed the Arkansas Medical Society members.
Dr. Larry Lawson gave an update on the sale of the
AMS Management Company which was completed
earlier this year. Dr. Lawson explained a letter was
sent to gauge the interest of physicians in purchasing
stock. A decision is pending before the AMCO board
on whether to make a stock offer.
Mike Mitchell reported on the Any Willing Provider
lawsuit. A decision on the case is pending before Judge
Moody. All of the briefing and oral arguments have
been completed and a decision is expected before the
end of the year.
Dr. Gerald Stolz, Chairman of the Council, made a
special presentation to Ken LaMastus in honor of his
twentieth anniversary vdth the Arkansas Medical Society.
Arkansas State Senator Mike Ross from Prescott ad-
dressed the House of Delegates on topics including
welfare and tax reform, Medicaid, prison overcrowd-
ing, and the Any Willing Provider law. Senator Ross
serves on the Public Health, Welfare, & Labor Committee.
Lynn Zeno, Director of Governmental Affairs, dis-
cussed proposed legislative issues for the 1997 Arkan-
sas General Assembly. A few of the "hot" issues in-
clude a bill to define the responsibilities and authorize
the use of medical assistants by physicians; bill to al-
low CRNA's to practice independently without physi-
cian supervision; bill to expand the optometry scope
of practice; Patient Protection Act II; and Medicaid re-
form. State Representative Scott Ferguson joined Lynn
in the discussion. The January issue of The Journal of
the Arkansas Medical Society will include additional in-
formarion regarding the upcoming Legislative Session.
Mike Mitchell discussed a request from the Arkansas
Dental Association to parHcipate in the Arkansas Medi-
cal Society's impaired physicians program. This would
be at no additional cost to the Society. Upon motion
the House voted to allow the dentists to participate
with final approval coming from the AMS Executive
Committee after details are complete.
A motion was made for the Arkansas Medical Society
to go on record as being adamantly opposed to the
Optometric Scope of Practice Act as currently written.
The House approved this motion which was followed
by a substitute motion to approve the entire legisla-
tive agenda as presented to the House. The House of
Delegates approved the substitute motion.
There being no further business the meeting adjourned.
396
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
1997
Arkansas Medical Society
Doctor of the Day^^
Program Calendar
r,i
The Arkansas Medical Society Department of Govern- I
mental Affairs appreciates the participation by the many g
physicians who are volunteering their time to serve as ^
"Doctor of the Day" during the 81st General Assembly.
The Society feels that in addition to the service provided
to the legislators, the more AMS members we can in-
volve in the legislative process the better.
The following pages list a calendar of physicians by day
of volunteer service. The Society recognizes and extends
a special thanks to "Doctors of the Day" participants.
Volume 93, Number 8 - January 1997
397
JANUARY 1 997
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Charles W.
Ball Jr., MD
North Little Rock
FP
Jim
Ingram, MD
Little Rock
AI
Thomas L.
Lewellen, DO
Star City
FP
J. Timothy
Dow, MD
Jonesboro
FP
Nathan
Austin, MD
Russellville
OTO
Tim T.
Wilkin, DO
Pine Bluff
FP
Charles S.
Rodgers, MD
Little Rock
FP
19
20
21
22
23
24
25
Charles W.
Smith, MD
Little Rock
FP
W. Wayne
Workman, MD
Little Rock
OBG
MarkE.
Miller, MD
Russellville
FP
Richard L.
Hayes, MD
Jacksonville
FP
Jeffrey
Carfagno, MD
Maumelle
FP
David H.
Taylor, MD
Searcy
IM/GI
J. Larry
Lawson, MD
Paragould
GS
J. Mayne
Parker, MD
Little Rock
OPH
16
27
28
29
30
31
Fred
Lyles, MD
Hot Springs
FP
James T.
Crider, MD
Harrison
FP
Dennis W.
Berner, MD
Russellville
IM
Charles R.
Feild, MD
Little Rock
PD
Don
Howard, MD
Fordyce
FP
J. David
Talley, MD
Little Rock
CD
Russell
Mayo, MD
Texarkana
FP
A. Bruce
Junkin, MD
Newport
FP
Dwight M.
Williams, MD
Paragould
FP
FEBRUARY 1 997
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1
2
3
4
5
6
7
8
Bruce E.
Schratz, MD
North Little Rock
FP
James
Arnold, MD
Fayetteville
ORS
Sidney P.
Hayes, MD
Little Rock
PUD
G. Scott
Harrington, MD
North Little Rock
FP
Roland C.
Reynolds, MD
Newport
FP
Kurtis
Vinsant, MD
Little Rock
GS/VS
H. Mark
Attwood, MD
Pine Bluff
FP
Joe H.
Stallings Jr., MD
Jonesboro
FP
David E.
Steams, MD
DeQueen
GS
9
10
11
12
13
14
15
Joe V.
Jones, MD
Blytheville
IMG
Nick J.
Paslidis, MD
Little Rock
IM
Scott
Dinehart, MD
Little Rock
D
Patricia J.
Wilson, MD
Little Rock
D
G. Dean
Ezell, MD
Russellville
IM
C. David
Williams, MD
Little Rock
CDS
Carl J.
Raque, MD
Little Rock
D
R. Mark
Dixon, MD
El Dorado
FP
Adalberto
Torres Jr., MD
Little Rock
PD/CCM
16
17
18
19
20
21
22
John W.
Baker, MD
Little Rock
GS
Ben J.
Kriesel, MD
Clarksville
FP
Thomas
Braswell, MD
England
EM
Joseph
Beck II, MD
Little Rock
ON
Jackie Coombe-
Moore, MD
Russellville
P
Andrew M.
Monfee, MD
Russellville
FP
Samuel B.
Welch, MD
Little Rock
OTO/HNS
James G.
Sheridan, MD
Piggott
IM
Stephen M.
Schexnayder, MD
Little Rock
PD/IM
S. Clark
Fincher, MD
Searcy
IM
23
24
25
26
27
28
James E.
Wise Jr., MD
Marvell
EM
Mike
Buffington, MD
DeQueen
FP
R. Kyle
Roper, MD
Smackover
FP
Thomas H.
Benton, MD
Salem
GP
Carlton L.
Chambers III, MD
Harrison
OTO
Dennis W.
Jacks, MD
Pine Bluff
U
Suzanne
Yee, MD
Little Rock
FPS/OTO
John W.
Smith, MD
Hot Springs
IM/NEP
Bruce K.
Burton, MD
Malvern
IM
James C.
Lambert, MD
Greenbrier
FP
MARCH 1997
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1
2
3
4
5
6
7
8
Gavin R.
Corcoran, MD
Pocahontas
IM/ID
David C.
Covey, MD
Searcy
IM
Darren E.
Flamik, MD
Little Rock
EM
William A.
Beck, MD
Little Rock
AN
Jim
English, MD
Little Rock
FPS/OTO
Francis M.
Henderson, MD
Mount Ida
OM
Jan R.
Sullivan, MD
Little Rock
N
Kimberly
Gamer, MD
Pine Bluff
FP
Hamilton R.
Hart, MD
Fayetteville
FP
Gregory S.
Hall, MD
Little Rock
EM
9
10
1 1
12
13
14
15
James
Suen, MD
Little Rock
OTO/HNS
Kelly H.
Meyer, MD
Danville
FP
Jerry L.
Harvey, MD
Pine Bluff
FP
Roger E.
Cagle, MD
Paragould
FP
Shirlene B.
Hill, MD
Lake Village
GP
Stevan M.
Van Ore, MD
Harrison
FP
James A.
Metrailer, MD
Little Rock
GE
Donald H.
Pennington, MD
Clarksville
FP
R. Jerry
Mann, MD
Cabot
FP
Julius
Sheppard, MD
El Dorado
ORS
16
17
18
19
20
21
22
James
Harrell Jr., MD
Little Rock
CDS
H. Graves
Heamsberger, MD
Little Rock
OTO
Leslie
Anderson, MD
Lonoke
FP
Herbert F.
Fendley, MD
Pine Bluff
FP/IM
Barry V.
Thompson, MD
Crossett
FP
Richard L.
Taylor, MD
Berryville
FP
Lawrence J.
Schemel, MD
Springdale
FP
Eugene M.
Shelby, MD
Hot Springs
EM
David L.
Stewart, MD
Benton
FP
23
24
25
26
27
28
29
David
Kolb, MD
Little Rock
EM
Steven W.
Strode, MD
Little Rock
FP
James
Meredith, MD
Forrest City
FP
Robert F.
McCrary Jr., MD
Hot Springs
NEP
Jim C.
Citty, MD
Searcy
FP
See Next
Page for
Monday,
Sandra L.
Snow, MD
Little Rock
PD
Steven L.
Thomason, MD
Cabot
FP
James
Zini, DO
Mountain View
FP
Kris B.
Shewmake, MD
Little Rock
PS
Sara
McBee, DO
Fayetteville
FP
March 31
APRIL 1997
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
March 30
March 3 1
This date open
for a volunteer
"Doctor of the
Day." Call
Laura Harrison
at 1-800-542-
1058.
1
John
Rayburn, MD
Hot Springs
EM
James C.
Yuen, MD
Little Rock
PS
2
Gary M.
Petrus, MD
North Little Rock
OTO
3
Omar T.
Atiq, MD
Pine Bluff
ON/HEM
H. Kevin
Beavers, MD
Russellville
IM
4
Daniel
Davidson, MD
Searcy
FP
5
6
7
C. Stanley
Applegate Jr., MD
Springdale
GP
8
David E.
Bourne, MD
Little Rock
FP
9
John M.
Hestir, MD
DeWitt
FP
10
F. Michael
Bauer, MD
Little Rock
CDS
11
James E.
Kelly III, MD
Fort Smith
PS/HS
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Special Article
The Patient's Right to Know - Full Disclosure
Laws are Necessary for Patients and Physicians
John Troupe, M.D.*
Increasing health care costs, overutilization, and
the demand for alternatives to traditional fee-for-service
care have led to the development of managed care,
with its own risks of underutilization, and conflicts of
interests that risk destruction of the doctor-patient re-
lationship, the vital interface where treatment deci-
sions have been made. Increasingly, treatment deci-
sions are controlled by managed care organizations
who provide physicians with incentives to withhold
treatment. Whereas recommendations for treatment
allow the opportunity for query, withholding treat-
ment information deprives the patient of the knowl-
edge necessary to make informed choices, and plans
that encourage such veiling should be brought into
the light.
Physicians, already in abundance, have seen little
alternative than to cooperate with the managed care
organizations. From 1975 to 1985 the number of new
licensed medical doctors increased 40% while patient
visits per week dropped 21%.’ This decreasing patient
load has made many physicians (particularly the young
ones with massive debt), amenable to nontraditional
plans that provide a stream of income. Managed care
organizations sometimes use coercion to gain physi-
cian cooperation. For example, the organizations en-
ter small towns, contract with employers to provide
services, and make arrangements with the sole hospi-
tal to serve as the admitting facility. Then they gather
the community physicians and smugly proclaim,
"[Ijadies and gentlemen, we control your patients, we
control your hospital, now here is the deal we have
for you." This leaves the physician with a choice of
caving to the demands of the payor, or relocating his
practice (sometimes after rearming with a law degree).
Although the ideal of working for the best inter-
ests of the patient is a basic principle in medical eth-
ics, the principle of autonomy demands attention to
the demands of the patient, and some patients may
be tolerant of conflicts of interest in exchange for man-
aged care, as long as they know of the conflicts are
inherent with these plans.
* John Troupe, M.D., is a 1978 graduate of the University of
Tennessee Center for Health Sciences in Memphis. He dosed
his ophthalmologic practice in Harrison, Arkansas, to pur-
sue a law degree at the University of Arkansas in Fayetteville.
Individual physicians could be required to disclose
to the patient the parameters of her compensation ar-
rangements with the patient. Disclosure requirements
already exist for incentives to overutilize. At the Fed-
eral level, the Stark bills (42 U.S.C. § 1395) prohibit
some referrals to physician owned facilities. Some states
require disclosure of ownership interests in facilities
or organizations to which they refer patients. Under
California law,^ physicians are prohibited from refer-
ring a patient to an organization in which the physi-
cian has a significant financial interest (the lesser of
5% or $5000 ownership) without disclosing the inter-
est in writing to the patient and advising him of his
right to obtain services elsewhere. Florida prohibits
referrals of patients to business entities in which the
physician has an equity interest of 10% or more unless
the patient has received prior notice of the financial
interest and of his right to obtain services elsewhere.^
Massachusetts requires a physician, upon referring a
patient for physical therapy, to disclose any financial
ownership interest in the physical therapy facility and
to inform patients of their right to obtain services elsewhere.^
Requiring the physician to disclose the existence
of financial incentive under the doctrine of informed
consent is not the best solution. The retrospective na-
ture of the tort system can only offer after-the-fact com-
pensation for any harms that the patient might have
suffered because he did not know the physician was
being given financial incentives to provide less care.
Because informed consent is a negligence concept, the
patient would have to demonstrate 1) that the doc-
trine of informed consent has been breached by non-
disclosure of the financial incentive arrangement; 2)
that the breach proximately caused harm; and 3) that
if the patient had been informed about the existence
of the arrangement he would have sought care from a
another provider using his own resources or would
have actively petitioned the health plan for the treat-
ment using established grievance procedures.^ It would
be very difficult to establish that a patient was physi-
cally harmed by nondisclosure.
There are other problems with using the doctrine
of informed consent. Despite the existence of a physi-
cian financial incentive arrangement, the physician has
the primary authority to make treatment decisions and
402
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
the presumption will likely be that she made the deci-
sion based on medical appropriateness, absent strong
evidence to the contrary.'’ If physicians are required to
disclose arrangements as part of their duty to disclose
all information material to the treatment decision, the
patient will receive this at an awkward point - when
the patient is processing often overwhelming clinical
information. If the patient receives information about
financial incentives when deciding whether to adopt
treatment recommendations, this may be too late. The
patient is already enrolled in the plan and may not be
able to seek care elsewhere. Also, requiring the physi-
cian to disclose financial incentives would impugn the
physician's professional integrity when there is no evi-
dence that the arrangement is contaminating a par-
ticular treatment recommendation. The physician, with
her loyalty divided between the patient and the man-
aged care organization, may be reluctant to engage in
a detailed discussion of the arrangement and downplay
its significance. Thus, the disclosure may ultimately
distract the patient from the information she seeks.''
Physicians might be more comfortable disclosing ar-
rangements at the inception of the physician-patient
relationship, when there might be no pending treat-
ment decision but there could be a resulting breach of
trust with greater harm than absence of disclosure.
Patients expect that physicians will advocate on their
behalf, and losing faith in the person who can help in
a crisis can "cripple the foundation of hope essential
to recovery."*
A patient would be better off receiving informa-
tion on incentive arrangements directly from the health
plan. If the patient does not approve of his physician
being paid in a way that provides a disincentive to
give care, he can seek out a health plan that compen-
sates physicians in an acceptable way - assuming pa-
tient choice still exists.
An appropriate place for the impetus for such dis-
closure might be on the managed care organization.
According to one commentator, "disclosure of such
information as maximal benefits covered misleads sub-
scribers who are not told of specific rules and incen-
tives designed to make it unlikely these benefits will
be offered."’
Federal law already requires disclosure of certain
aspects of health plans to the enrollees. A written de-
scription of the health plan must be provided to en-
rollees and persons eligible to select an HMO as an
option. The description is to provide "full and fair dis-
closure" of the elements of the plan, including partici-
pating providers, service area, benefits, procedures to
be followed in obtaining benefits, and a description of
circumstances under which benefits may be denied.’”
Incentives to withhold treatment constitute circum-
stances under which benefits may be denied.
Federal law requires that HMO's establish griev-
ance procedures, whereby enrollees can contest utili-
zation review decisions that a particular treatment is
not medically necessary.” Several states also have stan-
dards for HMO's and entities that practice utilization
review that include the requirement of an appeals pro-
cedure for adverse decisions.'^ The existing grievance
mechanism could be extended to allow members to
complain that financial incentives encouraged
nonreferral. The member could argue that knowledge
of compensation used in her health plan empowered
her to take a more active role in decisions affecting her
health care. However, disclosure of and consent to
incentives to withhold treatment would make this
unnecessary. The Arkansas General Assembly has
provided a statutory framework for the regulation of
managed care” which includes disclosure of informa-
tion to enrollees.” I propose an amendment to require
explicit disclosure of incentives to withhold treatment.
A bill has already been drafted to task an administra-
tive agency” with developing standards for the insur-
ance commission, which oversees managed care orga-
nizations.”
House Bill 2094, which was introduced in the 80'*
Session of the Arkansas General Assembly (1995), ad-
dressed disclosure of incentives to withhold treatment,
but the tactics of lobbying might be more effectively
applied to a statutory amendment.” The amendment
requiring explicit disclosure of incentives to withhold
treatment could "set the stage" for more comprehen-
sive regulation of the managed care industry.
In conclusion, patient autonomy demands that the
patient be informed of his treatment options. When
the doctor patient relationship is distorted to encour-
age withholding of treatment options, the patient must
at least be informed. Prohibition of incentives is un-
likely. The modest proposal outlined in this paper of-
fer the possibility that patients can continue to make
informed choices.
References:
1. Clemons P. Work & Maureen Walsh, It's Fever Time For
Doctors, U.S. NEWS & WORLD REP., Jan. 1987, at 44.
2. CAL. BUS. & PROF. CODE 654.2(a) (Deering Supp. 1995).
3. FLA. STAT. § 458.327(c) (1991).
4. MASS. GEN. LAWS ch. 112 §12AA (West Supp.
1994).McGraw supra note 59 at 1843.
5. Deven C. McGraw, Financial Incentives to Limit Services:
Should Physicians be Required to Disclose These to Patients?,
83 Geo. L. J. 1821,1828 (1995).
6-8. Id. at 1845.
9. Douglas F. Levinson, Toward a Full Disclosure of Referral
Restrictions and Financial Incentives by Prepaid Health Plans,
317 NEW ENG. J. MED. 1729 (1987).
10. 42 C.F.R. § 417.124(b) (1994).
11. 42 C.F.R. § 417.124(g)
12. See, e.g., FLA. ADMIN. CODE ANN. act 59A-12.010
(1990); 902 KY. ADMIN. REGS. 20:054 (1994); MO. REV. STAT.
§ 374.510 (1991); TEX. INS. CODE ANN. art. 21.58A (West
Supp. 1995). 13. A C.A. § 23-76- 101.
14. A C.A. § 23-76- 114.
15. See Arkansas H.R. 2094, 80th General Assembly, Regu-
lar Session (1995) "AN ACT TO PROVIDE THAT THE AR-
KANSAS DEPARTMENT OF HEALTH SHALL ESTABLISH
STANDARDS FOR THE CERTIFICATION OF QUALIFIED
MANAGED CARE PLANS; AND FOR OTHER PURPOSES."
16. HMO Ark, Inc. v. Dunn, 840 S.W.2d 804 (1992).
17. Recent conversation with the Arkansas Medical Society
government affairs officer.
Volume 93, Number 8 - January 1997
403
Special Article
Arkansas Physicians in the AMA
Your Representatives to Medicine's
Strongest Voice
James M. Kolb, Jr., M.D.
Editors Note: Dr. James M. Kolh, Jr., served as AMS
President in 1994-1995. Since 1994, he has been an Alter-
nate Delegate to the AMA. Beginning in January of 1997,
Anna Redman, M.D., will assume this position.
Twice each year the Arkansas Medical Society sends
three delegates and three alternates to meetings of the
American Medical Association House of Delegates
(HOD). I am sure some of you wonder if this is money
well spent. What does the AMA do for me, us or the
American people? As a departing member of your
delegation, 1 will share with you my observations and
experiences and try to answer those questions.
The formula for representation in the AMA is one
delegate per 1,000 AMA members, or fraction thereof.
Arkansas could have two or three more if all eligible
physicians would "close ranks" with those of us who
do belong and join the AMA.
Your delegation is led very capably by Jack Burge,
M.D., of Lake Village. Other delegates are Drs. Jim
Weber, of Jacksonville, and Bill Jones, of Little Rock.
Alternates are Drs. John Hester, of DeWitt, Larry
Lawson, of Paragould, and my successor, Anna
Redman, of Pine Bluff.
To have a more effective delegation, Arkansas has
joined with Oklahoma, Kansas and Missouri to form a
much larger group known as the "Heart of America
Caucus." More responsibility has come with this asso-
ciation. For example, at the annual meeting this past
June, 1 was assigned to review and present to the Cau-
cus the reports and resolutions to be discussed in front
of Reference Committees B and D. This included ap-
proximately 17 reports, some quite lengthy and com-
plex, plus 62 resolutions. At each June meeting our
delegates are responsible for interviewing candidates
for four Councils and the Board of Trustees. It takes a
great deal of effort and time on the part of our staff
and delegates to produce the desired results; a stron-
404
ger voice in the AMA, thus a more effective represen-
tation for you.
The House of Delegates (HOD) addresses hun-
dreds of issues at every meeting within a five-day pe-
riod. Our U.S. Senators and Representatives could
learn from us how to function more efficiently.
There are usually nine reference committees, each
made up of delegates appointed by the AMA Speaker
of the House. Each is assigned resolutions submitted
by component societies, such as the Arkansas Medical
Society, in addition to reports and resolutions from
the Councils and Board of Trustees. Delegates and
members may discuss any issue before these reference
committees. The order in which these issues are heard
is predetermined by the Chairperson. No votes are
taken. It is the duty of the reference committee to de-
velop recommendations for the HOD based on the
discussion and their judgment. Each item is brought
before the HOD by number with the printed recom-
mendations available to the Delegates. "Things" move
very rapidly.
At the June 1996 meeting, two issues seemed to
dominate the agenda; Physician Assisted Suicide and
The Study of the Federation.
Physician Assisted Suicide - The national press with
their television cameras and note pads were constantly
in the hallways talking to physicians. They were also
in the HOD chamber looking for a division in physi-
cian opinions regarding the issue of physician assisted
suicide. The HOD held firm to its current policy that
physician assisted suicide is unacceptable to the pro-
fession of medicine. The answer to relieving pain is
not murder, but a renewed effort to get those who
suffer to a physician with skills in pain management.
The press quickly "faded away" - not interested in
any of our other deliberations.
The Study of the Federation - The second most
discussed issue in the hallways and conference rooms
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
was the Board of Trustee's Report on The Study of the
Federation. The buzz word was "inclusiveness." Sur-
prisingly, the report was adopted without any signifi-
cant debate on the floor. The report establishes a new
method of representation in the AMA. Association
members are currently represented through their state
medical society. As a result of the adoption of this
report, members will also be able to designate a spe-
cialty society to represent them, in effect giving them
dual representation. This proposal is an attempt to
increase AMA membership through the specialty so-
cieties' efforts to gain additional representation in the
HOD. It is also hoped to establish an ongoing dia-
logue with each and every specialty in order to pre-
vent being surprised should differences arise on any
issue. It is estimated that the HOD will increase in
numbers by 60% or more.
All actions of the HOD are reported in the Ameri-
can Medical News, but I have also seen between 15 to
20 articles in newspapers and magazines regarding
various issues addressed just this past June. Most give
the AMA credit for making policies that are leading or
have led to change in our society. The following are
just a few examples of these policies.
The Oklahoma Delegation submitted Resolution
425 Counseling and Testing of All Pregnant Women.
This was perhaps the most hotly debated issue dis-
cussed on the floor of the HOD. Recent studies have
confirmed that effective treatment is possible to pre-
vent many newborns delivered by HIV positive moth-
ers from contracting the disease if the mother is diag-
nosed and treated with drug therapy during preg-
nancy. With this scientific information. Dr. Jones suc-
cessfully led the "floor fight" against the Assistant
Surgeon General, the President of the American Acad-
emy of Obstetrics and many others "in high places."
The opposition was afraid that pregnant women would
not come in for prenatal care if they knew that an HIV
test would be given. However, it was and is the duty
of the AMA to establish standards of care based on
science. All agreed that counseling remains the "bed-
rock" of care for these individuals.
A report from the Council on Scientific Affairs was
adopted after being amended to read;
1. To promote physician office and other medical
settings as preferred settings in which to provide HIV
testing.
2. For physicians to make HIV counseling and test-
ing more available in a medical setting.
3. To monitor the use and efficiency of HIV home
test kits and their impact on public health efforts to
control the disease.
You can readily relate this call for action to the
frequently seen television ads for home test kits.
Another report from the Council on Scientific Af-
fairs - Fatigue. Sleep Disorders and Motor Vehicle
Crashes - was adopted. Here is an article, written by
medical writer Brenda C. Coleman, that recently ap-
peared in the Arkansas Democrat-Gazette.
Sleepyheads at wheel
Fatigue-related accidents called
"America's hidden nightmare"
CHICAGO (AP) - The secret killers on American high-
ways are drowsy drivers and it's time for doctors to do some-
thing about it, a medical panel says.
Drivers who aren't fully awake cause more than 1,500
traffic deaths a year. In 96 percent of the cases, the accidents
involve passenger cars, not commercial drivers. There are
about 43,000 vehicle deaths from all causes each year.
"This is America's hidden nightmare," said Dr. Will-
iam Dement, director of Stanford University's sleep disor-
ders program. He said the vast majority of highway acci-
dents are not properly investigated as fatigue-related.
A panel of the American Medical Association panel has
called on the AMA to suggest guidelmes for drivers to avoid
falling asleep at the wheel. The association's Council on
Scientific Affairs said more research, enforcement and edu-
cation are needed to keep drivers from becoming danger-
ously drowsy. The council also called for guidelines to li-
cense commercial and private drivers with sleep-related disorders.
The council made no specific rec-
ommendations about the regulation
of drivers with sleep disorders, which
can range from sleep apnea, in which
the momentary closmg of an airway
awakens a person repeatedly, to
chronic fatigue caused by a lack of
sleep.
"It's very poorly understood by
the American public," said Dement,
who also is chairman of the National
Commission on Sleep Disorders Research. "The American
Medical Association now has a chance to be a leader in this
whole area. "
The council recommends that:
* The National Institutes of Health and other groups
support more research on the prevalence of sleep-related dis-
orders.
* The Department of Transportation study the links be-
tween crashes and operator alertness and sleep.
* The AMA urge federal agencies to improve enforce-
At the annual meeting in June, Dr. Jones was a candidate for the
Council on Scientific Affairs. He came very close to winning a seat. It
usually takes a number of years as a delegate to win such a coveted posi-
tion on a Council or on the Board. Our delegation is proud of Dr. Jones
and the Arkansas Medical Society staff for their dedicated effort in that
nearly successful race. (Bill, you should try it again for I believe your mission
to the AMA will not be complete until your expertise is shared with the Council
on Scientific Affairs.)
Volume 93, Number 8 - January 1997
405
mejit of existing regulations for truck-driver work periods
and consecutive working hours, and increase awareness of
the hazards of driving while fatigued.
* The AMA urge physicians to learn more about sleep
disorders, treat them more effectively and educate patients
about them.
Commercial truck drivers must fill out log books verify-
ing the number of hours they are on the road to prevent
them from driving on too little sleep. But no regulation
exists for passenger drivers.
Dement said if the AMA passes the council's report and
recommendations, "it would just put this whole area right
on the front burner."
AMA policy has no legal force, but it does direct the
AMA's resources toward influencing legislators, doctors and
the public.
Resolution 429, Assurance of Public Health Aboard
Cruise Ships, was amended and adopted. This reso-
lution urges the development of standards for the pro-
vision of medical care aboard cruise ships either
through federal legislation or international treaty. An
article in the Arkansas Democrat-Gazette regarding the
need for standards of medical care reported a favor-
able response from cruise ship lines and the public to
the AMA recommendations.
And let's not forget the war on tobacco! The AMA
has long championed our efforts to reduce the use of
tobacco. Their relentless efforts to bring this problem
to the attention of the American public has paid big
dividends. Public policy toward smoking has under-
gone tremendous changes. The health status of thou-
sands of people has been affected by the AMA's battle
with the tobacco industry. Tobacco addiction among
children and the detrimental effects on their lives was
a major issue used by President Clinton during the
recent elecHons. President Clinton also "picked up on"
the AMA's call for educational television programming
for children. In June, the HOD recommended at least
six hours per week. Due largely to that recommenda-
tion, it is now law that each station broadcast at least
three hours of educational programming for children
per week.
The relevance of the AMA's actions in our daily
lives goes on and on!
Those physicians who are members of the AMA
are to be commended, for this country is a much bet-
ter place to live because of the actions of the House of
Delegates.
May I recommend to you who are not members...
join this month!
It has broadened my medical knowledge to have
been an alternate delegate. I thank you for allowing
me this experience. I do encourage my former fellow
delegates to bring to you the highlights and important
issues by way of monthly articles in your journal. The
Journal of the Arkansas Medical Society.
<
Q
O
H
Other than this...
There are only two better vehicles for reaching
Arkansas’ physicians and health care providers.
The Journal of the Arkansas Medical Society
and
The Arkansas Medical Society Membership Directory
Call the Arkansas Medical Society today at
501-224-8967
to inquire about rates and other advertising information.
n
>
r
H
O
o
406
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Loss Prevention
Hazards of Heparin
J. Kelley Avery, M.DA
Introduction
In large hospitals where significant numbers of
cardiovascular surgical procedures are done, and where
cases of deep vein thrombosis and pulmonary embo-
lism are all too common, heparin medication becomes
so routine that its hazards come to be minimized in
the management of these problems. The following case
is an example of this danger.
Case Report
A 71-year-old man with multiple health problems
had in the past been hospitalized for a bleeding gastric
ulcer, acute urinary retention, prostatic cancer with
transurethral resection of the prostate (TURP), COPD,
and hematuria thought to be due to a post-TURP stric-
ture of the urethra. He was a known type II diabetic,
and had been seen in the hospital emergency room for
blood pressures of 220-200/120-110 mm Hg.
This present illness and hospitalization was
brought about by a history of sleep apnea, which had
been investigated in the sleep laboratory of another
hospital. The patient was thought to have "redundant
pharyngeal tissue" that should be treated surgically.
In the preoperative workup by a cautious otolaryn-
gologist, a history of exertional chest pain was discov-
ered, causing the internist to admit his patient to the
hospital. His admission history did not record the pre-
vious bleeding gastric ulcer, which had been treated
in another hospital, but did carefully document the
exertional discomfort that had been getting worse for
the past few months, and the other health problems
that were a part of the record at this hospital. The
physical examination was not remarkable, and the labo-
ratory work was within normal limits, with a hemat-
ocrit of 44.2%. A cai'diologist was consulted, and car-
diac catheterization was scheduled. A severe degree
of stenosis was found in the left anterior descending
coronary artery (LAD) with less obstruction in the right
coronary artery. The circumflex artery was said to show
Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Co., Brentwood, TN. This
article appeared in the Journal of the Tennessee Medical Associa-
tion in July 1993, It is reprinted here with permission.
some "irregularities without narrowing." Angioplasty
done two days after the initial catheterization failed to
open the LAD, and in fact, some slowing of the flow
was observed distal to the point of the dilatation site.
An emergency coronary artery bypass graft (CABG)
was done, with routine heparinization prior to the
catheterization and surgery. Post-CABG the hematocrit
was 40%. Bloody urine was noted per Foley catheter.
The day after surgery the hematocrit was recorded
at 34.1% Heparin was ordered at 100 mg every eight
hours and the following day the hematocrit was 28.6%.
The patient began to complain of nausea, for which
symptomatic treatment was given. When the hemat-
ocrit appeared to stabilize for a day or two, heparin
was continued. By the third postoperative day, the
patient had begun to have more abdominal discom-
fort, and while standing at the bedside he began to
retch and vomit green emesis. The abdominal discom-
fort continued but was easily managed. Iron was given
on the fourth postoperative day, with the hematocrit
at 26%. Nausea continued, and some abdominal dis-
tention was noted. Some serosanguineous fluid was
noted oozing from the incision, and another cardiac
surgeon was asked to follow the patient because he
was thought to have more experience with wound
management and could offer the patient a better out-
look. During this day the patient began to have some
shortness of breath. Small, loose stool was reported
but not described. Heparin was continued.
On the fifth postoperative day the hematocrit was
22.1%. Two units of packed red blood cells were given.
A "good BM" was reported the following day but not
described. An order was written to check all stools for
blood. On the seventh postoperative day a black stool
was reported, and thereafter all stools were reported
4+ for blood. Heparin was continued, and the hemat-
ocrit remained at 22%. On the night of the eighth post-
operative day the patient became disoriented, and upon
being turned on his side the following morning dur-
ing his bath, respiratory arrest occurred. Resuscita-
tion was not successful. An autopsy reported "exsan-
guination from a large gastric ulcer that had eroded
into a medium-sized gastric artery." The 100 mg hep-
arin flushes were continued during the last day of this
man's life.
Volume 93, Number 8 - January 1997
407
Both the internist and the surgeon were named in
the lawsuit that was filed in this case, and a large settle-
ment was negotiated.
Loss Prevention Comments
Perhaps the initial lesson to be learned from this
case is that the past history must be complete and not
limited to the patient's history in one institution or
with one physician no matter how long and varied
that history is. This patient's history of a bleeding ul-
cer at another institution was not part of his record of
his last admission.
Of course, the tragic terminal event of massive GI
bleeding could have occurred even had the heparin
therapy been stopped days earlier. The PT/PTT deter-
minations had not indicated that too much anticoagu-
lant was being given. It would appear that the routine
use of heparin in all CABGs had become so established
that it escaped the daily evaluation of this patient's
condition. Thus the abdominal symptoms and their
possible implications were ignored.
It would be well to look carefully at your
institution's "Adverse Drug Reactions" for heparin. If
it is significant (and it probably is), consider develop-
ing a physician-led team to develop an institution-wide
protocol for heparin use in all of its indications. That
exercise could result in the prevention of patient in-
jury, and thus real medical malpractice loss prevention.
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408
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas Medical Society
Day at the Capitol
i
Wednesday, February 5, 1 997
Morning Program
Little Rock Hilton
925 South University
Little Rock, Arkansas
Evening Reception
Aerospace Education Center
330 1 E. Roosevelt Road
Little Rock, Arkansas
Arkansas Medicai Society members, spouses, ciinic managers and guests are invited to
the bi-annuai "Day at the Capitoi" program on Wednesday, February 5, 1 997. This
important event wiii begin with a morning iegisiative briefing at the Littie Rock Hiiton,
foiiowed by a visit to the State Capitol.
Whiie visiting the State Capitoi, personaiiy invite your iocai iegisiator to join us at 6:30 p.m. for a
reception honoring the Arkansas Generai Assembiy at the Aerospace Education Center
(IMAX Theater). Look over the impressive faciiities of the Aerospace Education Center and enjoy
watching the Arkansas Razorbacks piay the Tennessee Volunteers. (Tip-off is at 7:05 p.m.)
The Covernmentai Affairs Councii invites everyone (physicians^ spouses, ciinic managers
and guests) to attend aii day, but especiaiiy encourages your attendance at the evening
reception, it is imperative to have one member per iegisiative district.
Scheduie of Events
Visit State Capitol 1 :30 p.m.
AMS Council Meeting 4:00 p.m.
Evening Reception 6:30 p.m.
Morning Registration
Legislative Briefing
Lunch
9:30 a.m.
10:00 a.m.
Noon
Legislative issues are won by those who show up!
Registration Form
Registration Fee: Lunch fit Reception $35 per person Indicate # Attending
Lunch Only $ 1 5 per person Indicate if Attending
Reception Only $25 per person Indicate U Attending
Name(s) (Please Print):
Address:
Phone:
Please send registration form and check to; AMS, PO Box 55088, Little Rock, AR 72215-5088.
Cardiology Commentary and Update
Ruxana Sadikot, M.D.*
Naresh Patel, M.D.**
Eugene Smith, M.D.**
Joe Bissett, M.D.**
J. David Talley, M.D.**
Lidocaine-Induced Cardiac Asystole
Lidocaine is used widely for the treatment of ven-
tricular arrhythmias, especially in the setting of an acute
myocardial infarction. The safety of intravenous
therapy with lidocaine is a major reason for its popu-
larity. Adverse effects to lidocaine are dose-related and
manifest mostly as central nervous system toxicity.
Sinus node depression is a rare complication of
lidocaine administration, when used singly or in con-
junction with other antiarrythmic agents. Sporadic case
reports have appeared describing this rare but fatal
complication.’’^ We report a patient with lidocaine in-
duced asystole who was on digoxin and amiodarone.
Patient Presentation
A 65-year-old white male, presented to the emer-
gency room following a rollover motor vehicle acci-
dent. He had a complicated past medical history which
included prior coronary artery bypass graft surgery, a
cerebrovascular accident, non-insulin dependent dia-
betes mellitus, atherosclerotic peripheral vascular dis-
ease, hypothyroidism, systemic arterial hypertension
and hyperlipidemia (see Complete Problem List, Table
1). His medication included ticlopidine, gemfibrosil,
enalapril, synthyroid, digoxin (0.125 mg qD) and
amiodarone (200 mg qD). In the Emergency Depart-
ment, he was unconscious with an irregular pulse rate
of 102 beats per minute, and the blood pressure was
150/78. Telemetry monitoring revealed frequent pre-
mature ventricular contractions and some of these
appeared as couplets. A twelve -lead electrocardiogram
showed normal sinus rhythm, multiple ventricular
premature complexes, seen in isolation and in pairs,
and an intraventicular conduction delay of the left
bundle branch block type (Figure 1). Electrolytes were
normal with potassium of 4.8 and magnesium of 1.7.
Hemoglobin and hematocrit were 11.7 and 31.2 respec-
tively. He was treated with a bolus of intravenous
lidocaine (100 mg), followed by an infusion at a rate of
* Dr. Sadikot is from the Department of Internal Medicine, UAMS
Medical Center.
** Drs. Patel, Smith, Bissett and Talley are with the Division of
Cardiology, Department of Internal Medicine, UAMS Medical
Center.
2 mg/min. Within minutes of receiving the lidocaine
he developed asystolic pauses more than nine seconds
in duration and required brief support with a transcu-
taneous pacemaker (Figure 2). The lidocaine infusion
was discontinued. No further asystolic pauses were
recorded and his arrhythmias were controlled with
intravenous amiodarone. He eventually had a stormy
course in the intensive care unit due to multiple medi-
cal problems and died after 6 days.
Discussion
Lidocaine, a widely used local anesthetic, was first
used as an antiarrythmic agent in the 1950's, to treat
arrhythmias induced by cardiac catheterization.^ It has
a low incidence of toxicity and very often is the first
drug of choice in the management of ventricular
arrhythmias. The benefit of lidocaine as a prophylac-
tic agent for ventricular arrhythmias in patients with
myocardial infarction is questioned and current Ameri-
can College of Cardiology/American Heart Association
guidelines discourage its use in this setting.®'^
Lidocaine suppresses the electrical activity of the
depolarized, arrythmogenic tissue while minimally in-
terfering with the electrical activity of normal tissues.
It acts exclusively on the sodium channels and blocks
both activated and inactivated channels. Recovery from
the block is very rapid and hence it has a greater effect
on the ischemic tissue. Lidocaine decreases automa-
ticity by reducing the slope of phase 4 and altering the
threshold for excitability. It has little effect on atrial
fibers, does not affect conduction in accessory path-
ways, and is of little use in the treatment of supraven-
tricular arrhythmias.
It has been reported to suppress the sinus node
activity in sick sinus syndrome.^ It rarely suppresses
activity of normal sinus node at therapeutic dosage,’’^
but this complication has been reported when the drug
is administered along with other antiarrythmics like
quinidine, phenytoin, amiodarone and digoxin. The
mechanism of sinus arrest is enhanced depression of
diastolic depolarization of the sinoatrial node and sup-
pression of impulse formation.
410
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table 1
lisease
Atherosclerosis
B. Systemic Arterial Hypertension
C. Diabetes Mellitus
A. Coronary artery bypass graft surgery, 1989
B. Echocardiogram concentric left ventricular hypertrophy,
dilated left ventricular cavity
Electrocardiogram normal sinus rhythm, intra-
ventricular conduction delay,
multiple ventricular complexes
B. Echocardiogram -> apical akinesis, ejection fraction
<20%
C. Rhythm strip prolonged sinus pause treated with
temporary pacing
Functional Assessment: Severely compromised
Objective Assessment: Severely compromised
2. Non-insulin dependent diabetes mellitus
3. Systemic arterial hypertension
4. Hyperthyroidism
5. Prior cerebral vascular accident, 1996
Heart Disease
Etiology:
A.
B.
C.
Anatomy:
A.
B.
Physiology:
A.
B.
C.
1. 12-lead electrocardiogram reveals normal sinus rhythm, multiple ventricular prema-
ture complexes, seen in isolation and in pairs, and an intraventicular conduction delay of
the left bundle branch block type.
2. Rhythm strip of the prolonged sinus pause (more than nine seconds in duration)
after lidocaine was administered. The patient had previously been receiving digoxin
(0.125 mg qD) and amiodarone (200 mg qD). The pauses were treated with temporary
cardiac pacing and resolved after the lidocaine was stopped.
Lidocaine has extensive first pass he-
patic metabolism, with only 3% of orally
administered lidocaine appearing in the
plasma. It is administered in 2-3 intrave-
nous boluses separated by 20-30 minutes,
to a total loading dose of 3-4 mg/Kg, fol-
lowed by an infusion at a rate of 1-4 mg/
min. Several factors require a reduction in
lidocaine dosing. Congestive heart failure
reduces the volume of distribution and
requires a lower loading dose and slower
infusion rate. Severe liver disease affects
drug metabolism and requires a lower in-
fusion rate. Advanced age increases the
likelihood of drug side effects and calls for
modifying both loading and maintenance
doses.
Most common adverse effects of
lidocaine are neurological and include
paraesthesia, tremor, nausea of cen-
tral origin, light headedness, hearing
disturbances, slurred speech and con-
vulsions. When given in large doses,
it may produce hypotension in pa-
tients with heart failure. Apart from
the interactions with the above men-
tioned antiarrythmics, it is also
known to interact with propranolol,
cimetidine and mexiletine.'* Propra-
nolol and cimetidine impair the dis-
position of lidocaine causing in-
creased in levels. Mexiletine lowers
the threshold of lidocaine toxicity;
hence the dosage of lidocaine should
be decreased, when administered
concomitantly.
In the patient presented, asystole
was probably due to an interaction
of effects of lidocaine, digoxin and
amiodarone. Pre-existing sinus node
dysfunction cannot be excluded. This
patient presentation describes a rare
complication of lidocaine, and is a re-
minder, that this medication should
be used judiciously in conjunction
with other antiarrythmic agents.
References:
1. Applebaum D, Halperin E. Asystole fol-
lowing a conventional therapeutic dose of
lidocaine. Am J of Emerg Med 1986;4:143-145.
2. Chang TO, Wadhwa K. Sinus standstill fol-
lowing lidocaine administration. JAMA
1973;223:790-792.
3. Marriott HJL, Philips K. Profound hypoten-
sion and bradycardia after a single bolus of
lidocaine. J Electrocardiology 1974;7:79-82.
4. Woosley RE. Antiarrhythmic drugs. In: Hurst's, The Heart, ed.
8, New York, McGraw-Hill, Inc., 1994: 775-805.
5. MacMahon S, Collins R, Peto R, Koster RW, Yusuf S. Effects of
prophylactic lidocaine in suspected acute myocardial infarction: An
overview of results from the randomized, controlled trials. JAMA
1988;26: 1910-1916.
6. Ryan TJ, Anderson JL, Antman EM, Braniff BA, Brooks NH,
Califf RAM, Hillis LD, Hiratzka LF, Rapaport E, Riegel BJ, Russell
RO, Smith EE III, Weaver WD. ACC/AHA guidelines for the man-
agement of patients with acute myocardial infarction: Executive
summary. A report of the American College of Cardiology/Ameri-
can Heart Association task force on practice guidelines
(committee on management of acute myocardial infarction. Circu-
lation 1996;94:2341-2350.
7. Lippestad CT, Forfang K. Production of sinus arrest by lignocaine.
Br Med J 1971;1:537.
8. Keidar S, Grenadier E, Palant A. Sinoatrial arrest due to lidocaine
injection in sick sinus syndrome during amiodarone administra-
tion. Am Heart J 1982; 104:1384-1385.
9. Jeresaty RM, Kahn AH, Landry AB Jr. Sinoatrial arrest due to
lidocaine in a patient receiving quinidine. Chest 1972;61 :683-685.
10. Agrawal BV, Singh RB, Vaish SK, Edin H. Cardiac awstole due
to lignocaine in a patient with digitalis toxicity. Acta Cardiology
1974;29:341-347.
StAtc ykskh Wa^tcli
Information provided by the Arkansas Department of Health, Division of Epidemiology
Reported Cases of Selected Diseases in Arkansas
Profile for October 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
Oct. 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1994
Campylobacteriosis
14
209
125
153
162
187
Giardiasis
19
139
111
131
108
126
Shigellosis
11
116
101
176
169
193
Salmonellosis
38
400
293
332
485
534
Hepatitis A
48
424
544
663
225
253
Hepatitis B
3
66
68
83
50
60
HIB
0
0
6
6
5
5
Meningococcal Infections
0
29
31
39
56
55
Viral Meningitis
2
30
31
31
62
62
Lyme Disease
2
23
10
11
15
15
Rocky Mountain Spotted Fever
1
21
31
31
18
18
Tularemia
1
19
20
22
20
23
Measles
0
0
2
2
1
5
Mumps
0
1
6
5
5
7
Gonorrhea
494
4369
4838
5437
5898
7078
Syphilis
41
644
892
1017
913
1096
Legionellosis
0
1
6
5
14
16
Pertussis
2
10
59
59
32
33
Tuberculosis
25
195
197
271
198
264
For a listing of reportable diseases in Arkansas, call the Arkansas Department of Health, Division of
Epidemiology, at (501) 661-2893 during normal business hours.
412
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
6arn credit in bhi/i cila/&>&room.
The beautijlujl outdoors o|[ Bi^ Cedar Lod^e in Bran/ion, /\i>&/&ouri
When was the last time you earned CME credit in a fun-filled, incredibly scenic environment? Nestled in the
beautiful Ozark Mountains, Big Cedar Lodge is the ultimate "classroom." Enjoy golf, tennis, horseback riding,
swimming, hiking and much, much more. All as the backdrop to a very important update on infectious disease.
The Injecbiou^i Di>&ea^e .Update - /\arch 7 and 6, 1??7
During the two-day session, specialists from Arkansas Children's Hospital and the University of Arkansos for
Medical Sciences - as well as several acclaimed guest speakers - will share invaluable information on a variety
of topics. Subjects include;
Antibiotic Jeopardy
The Evaluation of Children with Recurrent Fever
Pharyngitis
New Vaccines
Update on Polio & Pertussis Vaccines
The Use of Passive Immunizations in Children ..
When to Use Hepatitis A Vaccine
Red Book Update
Varicella Vaccine
J. Thomas Cross, M.D., MPH, Shreveport, LA
Susi Maxson, M.D., Ft. Worth, TX
Steven Nickerson, M.D., Tyler, TX
Gordon Schutze, M.D., UAMS/ACH
Richard Jacobs, M.D., UAMS/ACH
,J. Gary Wheeler, UAMS/ACH
Gordon Schutze, M.D., UAMS/ACH
Richard Jacobs, M.D., UAMS/ACH
Toni Darville, M.D., UAMS/ACH
For more information or reservations, call Kristi SchichtI in our CME office at (501) 320-1248.
Sponsored by:
ARKANSAS
CHn.DRFNTS
H O S PI T A L
C^Vi^OiM^CW/lDREM'S Z/VeS
UAMS
AAEDICAL
CENTER
Arkansas HIV/AIDS Report
1983-1997
HIV In
Arkansas
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501) 661-2387.
NOTE: County of residence may
change from date of HI V test to date
of AIDS diagnosis.
i('Miller|
90|:::-^ [~^ 1 | Columbi^
E (LafayeH^v Fl*
I County of residence at time of test for the 3,729 Arkansans reported to be HIV-positive (1 1/12/96)1
HIV
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
Male
100
215
248
413
400
392
352
367
338
250
3,075
82
X
Female
8
26
37
68
85
81
94
90
91
74
654
18
Under 5
1
1
2
8
13
6
3
7
2
1
44
1
5-12
0
1
1
5
1
2
1
0
1
0
12
0
13-19
0
7
8
14
19
25
11
22
12
20
138
4
20-24
12
40
52
71
44
49
64
60
47
27
466
13
25-29
21
70
71;
112
104
107
111
85
78
63
822
22
A
30-34
25
50
64
116
120
111
91
102
101
71
851
23
G
35-39
19
36
40
80
88
69
77
69
81
64
623
17
E
40-44
16
17
17
43
52
41
47
50
46
32
361
10
45-49
6
8
18
13
20
25
18
27
24
18
177
5
50-54
2
1
5
8
14
14
10
12
17
14
97
3
55-59
1
3
4
6
3
13
6
7
5
8
56
2
60-64
1
0
1
1
2
6
5
9
8
1
34
1
65 and older
4
2
1
2
3
5
2
7
7
5
38
1
R
White
87
170
174
328
298
293
278
260
260
171
2,319
62
A
Black
21
69
108
151
184
173
163
184
160
139
1,352
36
C
Hispanic
0
1
3
1
3
4
1
7
3
4
27
1
E
Other/Unknown
0
1
0
1
0
3
4
6
6
10
31
1
Male/Male Sex
65
138
144
245
250
261
242
230
167
115
1,857
50
Injection Drug User (IDU)
13
30
48
74
96
76
65
73
56
21
552
15
R
Male/Male Sex & IDU
19
23
24
32
30
34
26
23
27
17
255
7
1
Heterosexual (Known Risk)
5
25
26
59
67
68
100
96
69
51
566
15
S
Transfusion
5
7
4
6
8
10
0
2
3
1
46
1
K
Perinatal
1
1
2
8
13
8
4
7
0
0
44
1
Hemophiliac
0
0
6
18
5
6
2
3
5
0
45
1
Undetermined
0
17
31
39
16
10
7
23
102
119
364
10
HIV CASES BY YEAR
108
241
285
481
485
473
446
457
429
324
3,729
100
Arkansas Department of Health HIV/AIDS Surveillance Program
414
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1997
Reporting Requirements
HIV and AIDS case reporting by
name and address is required by Act
967 of 1991 and the rules and
regulations of the Arkansas Board
of Health. Reporting is required at
the time a person tests positive and
again when they become
symptomatic with AIDS. Those
required to report include:
physicians, nurses, infection control
practitioners/infection control
committees, laboratory directors,
medical directors of nursing homes
and home health agencies, clinic
administrators, program directors of
state agencies and other persons
required by the Board of Health.
Questions regarding reporting
forms and requirements may be
directed to Jan Bunch, HIV/AIDS
Surveillance Administrator, at
(501)661-2387.
NOTE: County of residence may
change from date of HI V test to date
of AIDS diagnosis.
AIDS
83-87
1988
1989
1990
1991
1992
1993
1994
1995
1996
Total
%
.:,S-
c.
Male
85
77
70
170
176
250
334
253
238
192
1,845
86
:-Xi
Female
5
6
10
20
25
35
64
42
36
49
292
14
Under 5
0
1
1
6
6
3
2
1
2
0
22
1
5-12
0
1
0
1
1
0
... 1
0
2
0
6
0
13-19
0
0
0
4
3
2
4
3
1
3
20
1
20-24
7
5
11
11
14
14
31
22
11
13
139
7
25-29
24
22
13
44
43
67
78
45
47
39
422
20
A
30-34
20
21
21
47
42
73
98
81
75
70
548
26
G
35-39
19
15
20
31
38
55
80
52
49
48
407
19
E
40-44
10
7
4
21
35
28
49
39
35 .
35
263
12
45-49
5
3
3
14
6
24
28
22
17
18
140
7
50-54
1
1
2
5
6
7
10
12
15
4
63
3
55-59
2
2
4
1
4
8
8
5
6
7
47
2
60-64
1
1
1
1
1
2
6
10
5
1
29
1
65 and older
1
4
0
4
2
2
3
3
9
3
31
1
'"m
White
74
61
58
141
134
206
273
190
174
132
1,443
68
Black
16
20
21
47
66
75
121
102
97
104
669
31
Hispanic
0
1
0
0
1
3
3
2
3
3
16
1
E
Other/Unknown
0
1
1
2
0
1
1
1
0
2
9
0
Male/Male Sex
55
59
50
122
120
183
237
166
138
108
1,238
58
Injection Drug User (IDU)
12
4
11
18
29
45
70
46
49
19
303
14
Male/Male Sex & IDU
. 16
6
6
18
17
21
27
23
^ 20
15
169
8
mm
Heterosexual (Known Risk)
5
3
7
11
12
24
52
41
35
36
226
11
■■S;:;;
Transfusion
2
7
3
7
11
4
2
4
3
1
44
2
K
Perinatal
0
1
1
6
6
3
3
1
3
0
24
1
Hemophiliac
0
1
1
5
5
4
5
6
7
1
35
2
Undetermined
0
2
1
3
1
1
2
8
19
61
98
5
AIDS CASES BY YEAR
90
83
80
190
201
285
398
295
274
241
2,137
100
Arkansas Department of Health HIV/AIDS Surveillance Program
AIDS In
Arkansas
AIDS CASES
REPORTED
□
1 to 3
□
4 to 49
□
50 to 99
■
100 to 704
I Of the 3,729 Arkansans report^
Volume 93, Number 8 - January 1997
415
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Getting Acquainted
Ben N. Saltzman, M.D.
Journal Editorial Board Member
Dr. Ben N. Saltzman, a retired physician and surgeon of Mountain Home, is
one of six editorial board members for The Journal of the Arkansas Medical Society. He
has been on the editorial board since its inception in March of 1988. Dr. Saltzman
has contributed greatly to the quality of The Journal by submitting numerous edito-
rials and by reviewing many scientific articles for publication consideration.
To him, being an active member of the AMS means having an opportunity to
meet with others in his chosen profession - to learn from them, to share in their
desire to help others by giving of themselves and their knowledge and to strive to
make the world a better place for future generations.
When asked what he believes is the most important issue facing the AMS, Dr.
Saltzman said, "It is important for AMS to continue to function as an organized
body in order to serve the people of our communities through doing the jobs we
have been trained to do in the most compassionate way possible. All things will
then fall in place naturally."
Dr. Saltzman's experience in the medical field is vast, to say the least. His
contributions - not only in medicine - but to his country and to Arkansas are
remarkable. After serving in World War 11 as a United States Army medical officer
in the early to mid-'40s. Dr. Saltzman settled in Mountain Home where he prac-
ticed medicine as a clinician for the next 27 years.
A pioneer of medical growth in northern Arkansas, Dr. Saltzman led a steer-
ing committee to handle the development of Baxter General Hospital; the first
hospital in the area. It opened in November of 1963.
In 1974, Dr. Saltzman was the first Professor and Chairman of the Department
of Family and Community Medicine at the University of Arkansas for Medical
Sciences where after seven years he retired as Professor-emeritus. He then went
on to serve as Director of the Arkansas Department of Health for six years and
finally retired after four more years as Medical Director of the Pulaski County
(Little Rock) Health Unit of the Department of Health.
Dr. Saltzman's participation in health- and community-related activities is as-
tounding. Throughout his career, he has served as President for nearly 15 profes-
sional and community organizations including the Arkansas Medical Society (1974-1975).
Nationally, he has served on the Boards of the American Lung Association
and the Association for Retarded Citizens. In Mountain Home, he served on the
city Council for seven years and four terms as President of the Chamber of Com-
merce. He is a 33rd degree Scottish Rite Mason, and for the past five years has
served as President of the Arkansas 4-H Foundation Board of Trustees.
Dr. Saltzman was born in Ansonia, Connecticut, on April 24, 1914. He re-
ceived his Bachelor of Arts, Master of Arts, and Doctor of Medicine degrees from
the University of Oregon. More recently, he received the Doctor of Science degree
from the University of Arkansas.
Dr. Saltzman was married to Ruth Elizabeth (Betty) Bohan. She died in May of
1994. They have four grandchildren and are the parents of three children. Sue
Ann, 51, a secretary and housewife of Arlington, Texas; John Joseph, 47, a railroad
engineer of Batesville, Arkansas; and Mark Stephen, 39, an airline pilot for Delta of
Dallas, Texas.
Hobbies: Fluorescent rock
collecting and demonstrating,
sphere making and polishing,
being a home handyman and
growing flowers.
If I had a different job, I'd
be: Wealthy
The person I most admire:
President Bill Clinton
Best Habit: Sleeping soundly
when I get the opportunity
Worst Habit: Contributing to
worthwhile causes, monetarily
One of my pet peeves:
Having my name placed on
contribution lists by people
who should know better. It
becomes a case of killing the
Golden Goose.
Favorite book, television
show and/or movie: I like
action stories in books, films
and videos
Favorite writer: Louis
L'Amour
Favorite actor: Chuck Norris
in Walker, Texas Ranger
The turning point of my life
was when: I married my
favorite nurse, Betty Bohan,
on December 19, 1941, in the
Panama Canal Zone
When I was a child, I wanted
to grow up to be: A doctor
My philosophy of life: In
tune with Barbara Streisand's
favorite song: I am the luckiest
person in the world in that I
need people
One word to sum me up:
Trusting
Volume 93, Number 8 - January 1997
417
New Members
ASHDOWN
Vorhease, James W,, Family Practice. Medical Edu-
cation, UAMS, 1980. Residency, Eglin Air Force Base,
Fort Walton Beach, Florida, 1983. Board certified.
BENTON
Woods, William K., Radiation Oncology. Medi-
cal Education, Albert Einstein College of Medicine,
Bronx, NY, 1990. Internship, Englewood Hospital,
Englewood, New Jersey, 1991. Residency, University
of California at Irvine, Orange, Calif., 1995. Board cer-
tified.
CLARENDON
Yunus, Nauman, Internal Medicine. Medical Edu-
cation, Dow Medical College, Pakistan, 1988. Intern-
ship/Residency, State University of New York, Stony
Brook, 1993/1995. Board certified.
EL DORADO
Parker, Arthur Wade, Internal Medicine. Medical
Education, University of Mississippi School of Medi-
cine, Jackson, 1981. Internship/Residency, UAMS,
1982/1984. Board certified.
FAYETTEVILLE
Murry, William Lee, Anesthesiology. Medical
Education, UAMS, 1987. Internship, AHEC-North-
west, 1988. Residency, UAMS, 1991. Board certified.
HARRISBURG
Bush, John M., Internal Medicine. Medical Edu-
cation, University of Tennessee, Memphis, 1992. In-
ternship/Residency, Medical College of Ohio, Toledo,
1993/1995. Board eligible.
HOT SPRINGS
Sorenson, Marney Keith, Surgery. Medical Edu-
cation, University of Texas Health and Science Cen-
ter, San Antonio, 1991. Internship/Residency, UAMS,
1992/1996. Board eligible.
LEWISVILLE
Bailey, Colin Raines, Family Practice. Medical
Education, University of Texas Medical School, Hous-
ton. Internship/Residency, Waco Family Practice Cen-
ter, Waco, Texas, 1996. Board certified.
418
LITTLE ROCK
Collins, Gary J., Cardiology. Medical Education,
Uniformed Services University of the Health Sciences,
Bethesda, Maryland, 1982. Residency, Wright-Patterson
USAE Medical Center, 1985. Board certified.
Dolak, James Alexander, Anesthesiology. Medi-
cal Education, Case Western Reserve University School
of Medicine, Cleveland, Ohio, 1991. Internship/Resi-
dency, Emory University Affiliated Hospitals, 1992/
1995. Board eligible.
Montgomery, Lori E., Pediatrics. Medical Educa-
tion, UAMS, 1989. Internship/Residency, Arkansas
Children's Hospital, 1990/1992. Board certified.
Nichol, Brian T., Anesthesiology. Medical Educa-
tion, UAMS, 1991. Internship/Residency, UAMS, 1992/
1995. Board certified.
St. Amour, Scott C., Radiology & Nuclear Medi-
cine. Medical Education, Rush Medical College, Chi-
cago, Illinois, 1990. Residency, Jewish Hospital of St.
Louis, 1994. Eellowship, Washington University Medi-
cal Center, St. Louis, 1995. Board certified.
MONTICELLO
Rodriguez, Paul Lopez, Radiology. Medical Edu-
cation, University of Tennessee, Memphis, 1966. In-
ternship, St. Joseph Hospital, Phoenix, Arizona, 1967.
Residencies, L.A. General Hospital and St. Joseph
Hospital, 1969/1970. Board certified.
NORTH LITTLE ROCK
Maxwell, Teresa Mamette, Family Medicine. Medi-
cal Education, UAMS, 1993. Residency, UAMS, 1996.
FARGOULD
Yamada, Ronald Ryo, Orthopedic Surgery. Medi-
cal Education, University of Chicago, Pritzker School
of Medicine, Chicago, Illinois, 1974. Internship/Resi-
dency, University of Southern California, 1975/1979.
Board certified.
RESIDENTS
Parchman, Anna Janette, Eamily Practice. Medi-
cal Education, UAMS, 1995. Internship/Residency,
UAMS, AHEC-Southwest.
STUDENTS
Michelle Lynn LaCroix
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
David Marshfield, M.D., Editor
Authors
Dean M. Moutos, M.D.
Michael M. Miller, M.D.
History:
A 38-year-old morbidly obese female presented with regular cyclical menses and primary infertility. Prior to
attempting a hysterosalpingogram (HSG), the scout film shown below was obtained. Due to the patient’s enormous
size and non-compliance, the HSG could not technically be performed.
Volume 93, Number 8 - January 1997
419
Calcified Uterine Leimyomata
Diagnosis: Calcified uterine leimyomata
Radiologic Findings:
A large multi-lobulated calcified mass is seen arising from the pelvis and extending into the lower abdomen.
Discussion:
Leiomyomas are common benign tumors of smooth muscle in the myometrium. They can be found in 20-30% of
women 30 years of age and older. They are frequently multiple, with each myoma originating from a distinct mono-
clonal cell that has undergone a somatic mutation which results in loss of growth regulation. Many leiomyomas are
cytogenetically abnormal with chromosomes 7, 12 and 14 most frequently affected. Malignant transformation to
leiomyosarcoma is thought to be extremely rare. Calcification of myomas frequently occurs after hemorrhage or
necrosis of the tumor.
Most myomas are asymptomatic and require no treatment. When symptomatic, myomas can cause pelvic
pain, menorrhagia, recurrent pregnancy loss and infertility. The peak incidence of symptomatic myomas requiring
treatment is in the 5th decade of life. Myomas generally regress and become asymptomatic after menopause.
Treatment of symptomatic myomas includes hysterectomy (for those women who have completed childbearing) or
myomectomy (for those women desiring to preserve their fertility). Myomas are usually suspected on pelvic exam
when an irregularly enlarged uterus is found. The diagnosis is readily confirmed with ultrasonography.
References:
1. Barbieri R, Andersen J. Uterine leiomyomas: The somatic mutation theory. Sem Reprod Endocrinol 1992; 10:301-9.
2. Cramer S, Patel D. The frequency of uterine leiomyomas. Am J Clin Pathol 1990; 94:435-8.
3. Verkauf B. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992; 58: 115.
Authors:
Dean M. Moutos, M.D., is with UAMS Department of Obstetrics and Gynecology.
Michael M. Miller, M.D., is with UAMS Department of Obstetrics and Gynecology.
Editor:
David Marshfield, M.D., is Director of Radiology at Riverside Imaging Center and Clinical Associate Professor of Radiology at
UAMS.
420
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
In Memoriam
Neil E. Crow, Sr., M.D.
Dr. Neil E. Crow, Sr., of Fort Smith, died Monday, November 1 1, 1996. He
was 71. He was preceded in death by his wife, Mary Katherine Crow. Survivors
are two children. Dr. Neil E. Crow, Jr., and Katherine Lee Crow Miller, both of
Forth Smith, and five grandchildren.
W. Payton Kolb, M.D.
Dr. W. Payton Kolb of Little Rock, died Sunday, December 8, 1996. He was
77. He is survived by his wife, Margaret Sparks Kolb of Little Rock; one daugh-
ter, Salli Kolb DeFoor of Little Rock; and one granddaughter, Amanda Dees of
Little Rock. Dr. Kolb was preceded in death by one son, Carl Kolb, who died in 1974.
Volume 93, Number 8 - January 1997
421
ARKANSAS AAEDICAL SOOETY
1997 ANNUAL CXM/ENTION
ARLINGTON HOTEL ♦ HOT SPRINGS, ARKANSAS
MAYI-3,1997
SCALING
NEW
HEIGHTS
Things To Come
February 8-10, 1997
12th Annual Mardi Gras Anesthesia Update in
New Orleans. Westin Canal Place Hotel, New Orleans,
Louisiana. Sponsored by the Department of Anesthe-
siology & Center for Continuing Medical Education,
Tulane University Medical Center. For more informa-
tion, call (504) 588-5466 or 1-800-588-5300.
February 9-14, 1997
Advances in Imaging: 1997. Manor Vail Lodge,
Vail, Colorado. Sponsored by the Departments of Ra-
diology at Tulane University Medical Center and Loui-
siana State University School of Medicine. For more
information, call (504) 588-5466 or 1-800-588-5300.
February 20-23, 1997
Current Issues in Gynecologic Endoscopy. The
Resort at Squaw Creek, Squaw Valley, California. Spon-
sored by the American Association of Gynecologic
Laparoscopists. For more information, call (310) 946-
8774 or 1-800-554-2245.
February 26-28, 1997
The Third National Primary Care Conference:
Community-Based Academic Partnerships. Washing-
ton Sheraton Hotel, Washington, DC. Sponsored by
Health Resources & Services Administration, U.S. De-
partment of Health & Human Services. For more in-
formation, call (301) 986-4870.
March 7-9, 1997
Management of the HIV-Infected Patient: A Prac-
tical Approach for the Primary Care Practitioner.
Crowne Plaza Manhattan, New York City. Sponsored
by the Center for Bio-Medical Communication, Inc.,
in collaboration with the American Foundation for AIDS
Research. For more information, call (201) 385-8080.
March 21-25, 1997
North American Skull Base Society 8th Annual
Meeting Combined with 2nd International Congress
on the Cerebral Venous System 2nd International
Congress on Meningiomas. The Excelsior Hotel, Little
Rock, Arkansas. For more information, call (301) 654-6802.
April 4-5, 1997
Clinical Pulmonary Update. Washington Univer-
sity Medical Center, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 10-12, 1997
Refresher Course & Update in General Surgery.
The Ritz-Carlton Hotel, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 25-27, 1997
1997 Pediatric Update for the Primary Care Phy-
sician. The Westin Canal Place, New Orleans, Louisi-
ana. Co-sponsored by the Alton Ochsner Medical Foun-
dation and Tulane University School of Medicine. For
more information, call (504) 842-3702 or 1-800-778-9353.
September 5-7, 1997
4th Annual Current Topics in Cardiothoracic
Anesthesia. Washington University Medical Center,
St. Louis, Missouri. Sponsored by the Office of Con-
tinuing Medical Education, Washington University
School of Medicine. For more information, call 1-800-
325-9862.
September 18-20, 1997
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
Volume 93, Number 8 - January 1997
423
Keeping Up
February 12, 1997
A.S.A.M.I. Seventh Annual Scientific Meeting. Time: 8:00 a.m. -
6:00 p.m. Location: ANA Hotel, San Francisco, California. Accred-
iting organization sponsoring program: UAMS College of Medi-
cine. Hours of Category 1 credit offered: To be determined. Fee: To
be determined. For more information, call (501) 661-7962.
March 1, 1997
Southwest Arkansas Physician Update. Time: 8:30 a.m. - 3:30
p.m. Location: Lile Hall, Quachita Baptist University, Arkadelphia.
Accrediting organization sponsoring program: UAMS College of
Medicine. Hours of Category 1 credit offered: To be determined.
Fee: To be determined. For more information, call (501) 661-7962.
March 1, 1997
Diabetes Update. Time: 8:00 a.m. - 4:00 p.m. Location: Little Rock,
Hilton Inn. Program presenters: UAMS Division of Endocrinology/
Arkansas Diabetes Program Course Director: Dr. Vivian Fonseca.
Accrediting organization sponsoring program: UAMS College of
Medicine. Hours of Category 1 credit offered: 5.5. Fee: Before Feb-
ruary 1, 1997, Physicians - $75 and others - $50; after February 1,
1997, Physicians - $100 and others - $60. For more information,
call (501) 661-7962.
March 1, 1997
Diabetes Update. Time: 8:00 a.m. - 4:00 p.m. Location: Little Rock,
Hilton Inn. Program presenters: UAMS Division of Endocrinology/
Arkansas Diabetes Program Course Director: Dr. Vivian Fonseca.
Accrediting organization sponsoring program: UAMS College of
Medicine. Hours of Category 1 credit offered: 5.5. Fee: Before Feb.
1, 1997, Physicians-$75 and others-$50; after Feb. 1, 1997, Physi-
cians-$ 1 00 and others-$60. For more information, call (50 1 ) 66 1 -7962.
March 4, 1997
Obesity: Common Symptom of Diverse Gene-Based Metabolic
Dysregulations. Time: 8:00 a.m. - 4:30 p.m. Loeation: Little Rock,
Excelsior Hotel. Program presenters: UAMS and Biochemistry and
Molecular Biology. Accrediting organization sponsoring program:
UAMS College of Medicine. Hours of Category 1 credit offered:
5.5. Fee: To be determined. For more information, call (501) 661-7962.
March 14-15, 1997
Neurology for the Primary Care Physician. Time: 8:00 a.m. -
4:00 p.m. Location: Little Rock, Hilton Inn Select. Program pre-
senters: UAMS Department of Neurology. Accrediting organiza-
tion sponsoring program: UAMS College of Medicine. Hours of
Category 1 credit offered: To be determined. Fee: $150 for Physi-
cians. For more information, call (501) 661-7962.
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category 1 of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon, Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Breast Conference, 3rd Thursday, 7:00 a.m., J.A. Gilbreath Conference Center, Room #20
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Disorders Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
424
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The University of Arkansas College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor the
following continuing medical education activities for physicians. The Office of Continuing Medical Education designates that these activities
meet the criteria for credit hours in category 1 toward the AM A Physician's Recognition Award. Each physician should claim only those
hours of credit that he/she actually spent in the educational activity.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Fetal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141 A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
Volume 93, Number 8 - January 1997
425
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas .
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology /Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical CenterJONESBORO-AHEC NORTHEAST
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital GME Gonference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
426
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 8 - January 1997
427
Advertisers Index
Advertising Agencies in italics
AMS Benefits 382
Arkansas Children's Hospital inside back
Arkansas Children's Hospital 413
Autoflex Leasing inside front
Consumer Quote USA 416
Freemyer Collection System 408
Medical Practice Consultants, Inc 387
Riverside Motors, Inc 390
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory back cover
Strategic Marketing
State Volunteer Mutual Insurance Company 378
The Maryland Group
Southwest Capital Management 385
Marion Kahn Communications, Inc.
U.S. Air Force 377
BJK&E Specialized Advertising
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
journal. Material appearing in The Journal of the Arkansas
Medical Society is protected by copyright. Manuscripts
may not be reproduced without the written permission of
both author and The Journal of the Arkansas Medical Society.
The Journal of the Arkansas Medical Society reserves the
right to edit any material submitted . The publishers accept
no responsibility for opinions expressed by the contributors.
All manuscripts should be submitted to Tina G. Wade,
Managing Editor, Arkansas Medical Society, P.O. Box
55088, Little Rock, Arkansas 72215-5088. A transmittal
letter should accompany the article and should identify
one author as the correspondent and include his/her
address and telephone number.
MANUSCRIPT STYLE
Author information should include titles, degrees,
and any hospital or university appointments of the
author(s). All scientific manuscripts must include an
abstract of not more than 100 words. The abstract is a
factual summary of the work and precedes the article.
Manuscripts should be typewritten, double-spaced, and
have generous margins. Subheads are strongly encour-
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Pages should be numbered. Manuscripts are not re-
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Along with the typed manuscript, we encourage you
to submit an IBM-compatible 5 1/4" or 3 1/2" diskette
containing the manuscript in ASCII format. The manu-
script on diskette must be in the same format as stated
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REFERENCES
References should be limited to ten; if more than ten
are listed, the author(s) may designate the ten most
significant to be printed and readers will be referred to the
authors(s) for the complete list. References must contain,
in the order given; name of author(s), title of article, name
of periodicals with volume, page, month and year. Refer-
ences should be numbered consecuHvely in the order in
which they appear in the text. Authors are responsible for
reference accuracy.
ILLUSTRATIONS
Illustrations should be professionally drawn and/or
photographed. Glossy black and white photos are pre-
ferred. They should not be mounted and should have the
name of the author(s) and figure number penciled lightly
on the back. An arrow should indicate the top of the
illustration. In photographs in which there is any possi-
bility of personal idenhfication, an acceptable legal release
must accompany the material. Up to four illustrations will
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are necessary, it is understood that the author(s) will be
responsible for the reproduction costs.
REPRINTS
Reprints may be obtained from The Journal office and
should be ordered prior to publication. Reprints will be
mailed approximately three weeks from publication date.
For a reprint price list, contact Tina G. Wade, Managing
Editor, at The Journal office. Orders cannot be accepted for
less than 100 copies.
THE Journal
OF THE Arkansas
MEDICAL SOCIETY
HEALTH SCIENCES LIBRARY
' " UNIVERSITY OF MARYLAND, AT
Volume 93 Number 3 ^ BALTIMORE February 1997
EB 7 1997
r-Ti
vn
oco
<c
What do you do? And
How well do you do it?
Climbing the academic ladder
while balancing on a
four-legged stool
- page 432
Recent trends in
physician services
market
- page 436
Market forces are
shifting physicians into
primary care
Learn how two physicians are
responding to the changing
healthcare delivery system
- page 449
Controversial
resolution regarding
the use of PVC in
healthcare facilities
- page 456
Plus much more inside...
J
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The Arkansas Medical Society has endorsed Autoflex Leasing for its
integrity, superior service record and flexible leasing plans . Volume
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Words we still live by at State Volunteer Mutual (SVMIC). As a
physician owned and operated liability insurance provider, we
have a compelling interest in the continuing education of doctors.
Every year, SVMIC conducts scores of Loss Prevention Seminars
to help impart the knowledge physicians need to face the ever
growing challenge of malpractice litigation. In addition, we
provide professional liability insurance at net cost, and we
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE PRESIDENT
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
Ohstetrics! Gynecology
Internal Medicine
Surgery
Family Practice
UAMS
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information: ContactTina G. Wade, The
journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster; Send address changes to: The journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
Press, Inc., Fulton, Missouri 65251. Periodicals postage
is paid at Little Rock, Arkansas, and at additional
mailing offices.
Articles and advertisements published in The journal
are for the interest of its readers and do not represent
the official position or endorsement of The journal or the
Arkansas Medical Society. The journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1997 by the Arkansas Medical Society.
Volume 93
Numbers February 1997
CONTENTS
FEATURES
432
Balancing on a Four-legged Stool
Editorial
Alex Finkbeiner, M.D.
434
Medicine in the News
Health Care Access Foundation Update
Physician-Assisted Suicide: What do the Elderly Think?
Postwar Morbidity and Mortality among Persian Gulf Veterans
Smoking Prevalence in the States
Recent Trends in Physician Services Market
443
New Member Profile
Deanna Nicholson Ruddell, M.D.
445
Socioeconomic Status, Race and Life Expectancy
in Arkansas, 1970-1990
David A. Swanson, Ph.D.
Mary A. McGehee, M.A.
449
Physician Training for Specialist to Generalist Career Change
Special Article
George M. Finley, M.D.
Rebecca Hyatt, B.S., G.P.M.
452
Defensible Case Made Indefensible
Loss Prevention
J. Kelley Avery, M.D.
DEPARTMENTS
438
AMS Newsmakers
454
Cardiology Commentary & Update
456
State Health Watch
458
New Members
459
Radiological Case of the Month
461
In Memoriam
462
Things to Come
464
Keeping Up
Cover photo provided by the Arkansas Department of Parks & Tourism.
Editorial
^alanclvg
on a Four-legged Stool
Alex Finkbeiner, M.D.*
After any prolonged conversation with a new ac-
quaintance the question of occupation invariably arises
- “What do you do?" As an academic urologist I have
always found it difficult to give a succinct reply.
I have been reflecting on this question recently as
the Promotion and Tenure Committee at UAMS, of
which I am a member, deliberated and made recom-
mendations regarding this year's candidates for pro-
motion and tenure. During evaluations of the candi-
dates one must ask of the candidate not only "What
do you do?" but also "How well do you do it?"
Historically, promotion and tenure (climbing the
academic ladder) was essentially based upon the "pub-
lish or perish" mantra by which one was judged by
scientific output most often reflected by journal publi-
cations. It was generally just assumed one adequately
performed one's teaching and other roles primarily due
to lack of objective criteria upon which to judge one's
effectiveness in these roles.
At UAMS we have attempted to define, evaluate
and reward clinical academic staff regarding the "What
do you do?" and "How well do you do it?" questions.
Each individual is expected to allocate a percentage of
their time amongst the four traditional roles of a medi-
cal academician (the four-legged stool): teaching, re-
search, patient care and service. Unlike a four-legged
stool, the distribution of workload may not necessar-
ily be distributed equally along each leg but will vary
amongst individuals. In turn, objective criteria have
been established for each of the four roles by which an
individual can be evaluated. By comparing the per-
centage of time allocated for each role to the criteria to
be met within each role the institution and the acade-
mician can better evaluate their job effectiveness while
using more objective criteria for rewarding them
through promotion and/or salary incentives. By better
delineating both the roles and the criteria for fulfilling
these roles it would appear that the "What you do
and how well" questions can be easily addressed. The
continually changing medical environment, however,
* Dr. Finkbeiner is Professor of Urology in the Department of
Urology at UAMS. He is a member of the editorial board for
The Jourtial of the Arkansas Medical Society.
forces us to continually reevaluate- these questions.
Let me try to explain why and expand the "What
do you do?" question. The major impact of what we
do and why we do it in academic medicine dates to
the mid-1960's when changes in financing medical
education commenced and continue to evolve to this
day. Since that time, federal and state monies to fi-
nance medical education have progressively dimin-
ished relative to the total financial needs of medical
institutions, and medical schools have been forced to
find alternative sources of income. Today, the major
source of funding for clinical academic medicine is by
fees generated through patient care, hospital and phy-
sician charges and collections. Federally funded re-
search grants are less readily available than in the past
and do not constitute a significant source of income
for most departments. Further, state appropriated
funds constitute less than 15% of our departmental
budget necessitating that over 85% of our department's
budget be derived from professional fees.
We in academic medicine are state employees in
that we are hired by and work for a state institution
and are governed by state employee regulations. Al-
ternatively, our reliance on over 85% of our operating
budget on professional fees generated by patient care
places us more into a private practice milieu. That is, a
major portion of our business expenses including sala-
ries for physicians, nurses, office personnel as well as
all fringe benefits, etc. are derived from professional
fees. Further, there are expenses not encountered in
private practice. Most expenses for resident education
such as books, journals, education seminars and pro-
fessional meetings are derived from professional fees.
Unless one has strong grant support, most scientific
and education endeavors by the academic physician
such as publication costs, expenses to attend meet-
ings to present one's research as well as local and state-
wide educational talks are financed from professional
fee income.
The reliance on professional fee income is further
complicated by the perception that UAMS and its af-
filiated institutions are the charity hospitals. It is com-
mon for patients to present to our clinics or for us to
432
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
receive phone calls from physicians referring patients
because the patients are indigent and/or have no medi-
cal insurance; they have not passed the "wallet biopsy"
test. The costs in man hours, supplies and equipment
incurred for caring for these patients are enormous to
both the University Hospital and to the individual
physicians. My personal collection rate is less than 50%
primarily because of the large indigent population
served. These patients truly need medical care, and
student and resident exposure to these patients con-
tribute to their education, but these nonreimbursed
services significantly impact on the allocation of the
academician's time and effort.
This brings us back to the four-legged stool. The
service leg includes institutional, departmental, com-
mittee and administrative activities which can be very
time consuming. The research leg is one of the two
traditional legs of academia (the other being educa-
tion). It is still the predominant leg upon which one is
judged academically, and to be productive in research
requires considerable time, effort and financial re-
sources. Education responsibilities are multiple and
diverse. These include didactic lectures, informal
rounds, conferences, seminars and teaching concomi-
tant with direct patient care. Students are as diverse
as medical students, nursing students, residents, fel-
low practitioners and/or lay groups. This vitally im-
portant role of teaching has traditionally been the most
difficult to define, quantitate and evaluate.
Three legs of service, research and teaching are
essentially non-income producing (unless one has sub-
stantial research grants) and frequently many gener-
ate expenses that must be paid from professional fees.
Within this context, the non-income producing indi-
gent care role must also be included.
With three legs of the four-legged stool not pro-
ducing income (four legs of a five-legged stool if pa-
tient care is split into indigent and non-indigent pa-
tients) a potential dilemma arises for both the institu-
tion and the individual academic physician. The di-
lemma being the pragmatic urge to shift one's weight
on the four-legged stool to one leg - the income pro-
ducing leg of patient care for paying patients who are
the financial life-blood for the institution, the depart-
ment and the individual physician. This becomes even
more compelling and attractive within the current en-
vironment of changing markets within medicine and
diminishing fees and income.
The consequences of this weight shift are obvi-
ous. As one devotes more attention, time and effort to
patient care one must either reduce time and effort
expended to one or more of the other three roles or
expand one's work week to simply maintain the time
and effort expended on those three roles. Many of us
are already maintaining a sixty-plus hour work week.
You non-academic physicians are directly impacted by
this dilemma of ours for this accentuates the old town
and gown issue. As we try to attract and maintain a
paying patient base we are competing with you for
the same patient population. We are competing for
these patients for the same reason you are - to pay the
bills. Further, we in academia are fully aware of the
irony of us educating and training medical students
and residents to go out and become our competition.
I suspect continued pressures will be exerted on
academic physicians to excel in all four of their roles,
but unless alternative sources of income can be found
the new mantra will be "publish and produce income
or perish." Further, we must do this while trying to
maintain excellence in our roles of service and teaching.
Other than this...
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Volume 93, Number 9 - February 1997
433
Medicine in the News
Health Care Access Foundation
As of January 1, 1997, the Arkansas Health Care
Access Foundation has provided free medical service
to 12,088 medically indigent persons, received 22,852
applications and enrolled 44,440 persons. This program
has 1,757 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
Physician-Assisted Suicide: What do the
Elderly Think?
Surveys of physicians and the general public show
a relatively high acceptance of physician-assisted sui-
cide (PAS). In this study, researchers at duke Univer-
sity focused specifically on the opinions of elderly pa-
tients and their family members. They surveyed 168
oriented elderly patients (average age, 76 years) being
seen at a geriatric specialty clinic for a variety of chronic
medical problems and 146 family members. Each group
was blinded to the responses of the other.
Only 40% of patients had favorable views toward
PAS in cases of terminal illness, compared to 59% of
relatives. Both groups were much less approving of
PAS in cases of chronic but not obviously fatal illness,
and in cases of mental incompetence. Patients with
the most favorable attitudes toward PAS were male,
white and had higher incomes and more education.
Family members were fairly poor at predicting the re-
sponses of their patient-relatives.
Comment; This is one of the first studies on atti-
tudes toward PAS to focus on frail elderly patients.
This group seems less enthusiastic about PAS than
younger persons surveyed in previous studies. Physi-
cians cannot look to family members to give accurate
guidance about their relatives' wishes in this matter. -
TL Schwenk
Koenig HG; et al. Attitudes of elderly patients and their
families toward physician-assisted suicide. Arch Intern Med
1996 Oct 28; 156:2240-8.
Reprinted by permission of Journal Watch, Volume
16, Number 23, December 1, 1996, issue. Copyright 1996.
Massachusetts Medical Society.
Postwar Morbidity and Mortality among
Persian Gulf Veterans
Some military personnel who served in the 1990-
91 Persian Gulf War have reported adverse health ef-
fects from infections, oil-well fires, chemical or bio-
logic warfare agents, and other causes. These two gov-
ernment-funded studies examined postwar mortality
and hospitalization among these veterans through late 1993.
First, researchers compared mortality data for
434
695,000 Gulf War veterans and 746,000 military per-
sonnel who served in 1990-91 but did not go to the
Persian Gulf. After adjustment for baseline differences
between the two groups. Gulf War veterans had a sig-
nificant 9% higher mortality rate during the two years
after the war. However, accidents - not diseases - ac-
counted entirely for the excess deaths.
The second study used similar methodology to
examine postwar hospitalizations. The overall rate of
hospitalization was not higher fqr Gulf War veterans
than for other veterans. Gulf War veterans had slightly
higher hospitalization rates for some diagnoses and
lower rates for others; however, there was no pattern
to these differences, with the possible exception of
excess hospitalization for alcohol and drug dependence.
Comment: These studies provide considerable re-
assurance, but do not exclude the possibility of war-
related physician ailments that did not result in sig-
nificant excess death or hospitalization. Moreover, the
increases in accidental death and alcohol- and drug-
related hospitalizations are noteworthy. - AS Brett
Kang HK; Bullman TA. Mortality among U.S. veter-
ans of the Persian Gulf War. N Engl J Med 1996 Nov 14;
335:1498-1504.
Gray GC; et al. The postwar hospitalization experience
of U.S. veterans of the Persian Gulf War. N Engl J Med
1996 Nov 14; 335:1505-13.
Reprinted by pertnission of Journal Watch, Volume
16, Number 24, December 15, 1996, issue. Copyright 1996.
Massachusetts Medical Society.
Smoking Prevalence in the States
In what the GDC calls a "milestone for public health
surveillance," the Council of State and Territorial Epide-
miologists recommended in June that cigarette smok-
ing be added to the list of conditions "reportable" to
the CDC by the states - the first time a behavior, rather
than a disease, has earned this dubious honor. This
report summarized state-by-state smoking rates for 1995.
Overall, the median U.S. smoking rate for people
over age 17 was 22.4%. Utah had the lowest rate (13.2%)
and Kentucky the highest (27.8%).
Some states have achieved major reductions in
smoking through physician advice, smoke-free indoor-
air policies, cigarette taxes and increased prices, and
counter-advertising campaigns. Between 1984 and 1995,
smoking prevalence in California declined from 26%
to 16%. A Massachusetts antismoking campaign and
excise tax increase on cigarettes (from 26 to 51 cents
per pack) beginning in 1993 lead to a decline of almost
20% in the packs purchased per adult.
Comment: Utah alone has achieved the year 2000
goal of an adult smoking rate of 15% or less. The Mas-
sachusetts and California experiences suggest that the
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Massachusetts programs began with a public ballot
initiative, suggesting a political will to reduce smok-
ing. - DM Berwick
State-specific prevalence of cigarette smoking - United
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Cigarette smoking before and after an excise tax in-
crease and an ayitismoking campaign - Massachusetts, 1990-
1996. MMWR 1996 Nov 8; 45:966-70.
Reprinted by permission of Journal Watch, Volume
16, Number 24, December 15, 1996, issue. Copyright 1996.
Massachusetts Medical Society.
Recent Trends in Physician Services Market
Results from the AMA's Socioeconomic Monitor-
ing System surveys indicate several interesting trends
in the medical practice marketplace.
Median physician net income (after expenses, be-
fore taxes) increased 6.7% in 1995, offsetting a 3.8%
decrease in the previous year. These opposing results
for the last two years illustrate the danger of drawing
long-term conclusions based on change in one year
alone. (The statistics in this report are for nonfederal
patient care physicians, excluding residents.)
The two-year change in income amounts to an
average annual increase of 1.3% from 1993 to 1995,
which, when adjusted for inflation, represents an av-
erage annual decline of 1.4% in real income. Since 1992,
median income increases have averaged 2.2%, below
the inflation rate of 2.8%.
For comparison purposes, national health expen-
ditures increased an estimated 6.1% in 1994, accord-
ing to the Health Care Financing Administration.
The long-term trend away from self-employment
and toward employee status continued in 1995. The
proportion of employee physicians grew from 36% to
39%. Nearly all of these additional employees came
from the ranks of self-employed physicians, whose
market share dropped to 55% from 58%. Since em-
ployees generally earn less than the self-employed,
the trend is one that would tend to restrain increases
in average physician income. The percentage increase
in income for self-employeds was greater than the in-
crease for employees in 1995.
Incomes of self-employed physicians are nearly
50% higher than those of employees. Part of the dif-
ferential is a return on entrepreneurship, investment,
and risk taking, over and above the compensation for
providing physician services. A differential is neces-
sary to attract capital to any enterprise. Other factors
contribute to the differential. For instance, self-
employeds tend to be older, have more years of expe-
rience, work more hours, and are more likely to be
board certified, all of which are associated with higher
earnings. Controlling for these factors, the income dif-
ferential due solely to employment arrangement would
be much less than 50%.
Three-fourths of employee physicians receive non-
436
cash benefits in addition to their reported income,
whereas some self-employed physicians do not. These
benefits are about 5% of income for employees. There-
fore, a comparison of total compensation would show
that the differential would be narrower than one based
on cash income alone.
Income varies considerably from one specialty to
another. In 1995, average income was lowest among
general/family practitioners and pediatricians and high-
est for radiologists and surgeons, among the special-
ties examined separately.
The change in income from 1994 to 1995 varied
substantially across specialties. Primary care special-
ties generally enjoyed increases that were greater than
the average for all physicians; the exception was the
broad category of internal medicine, for which me-
dian income was unchanged. Increases for surgical
specialties were below the all-physician average. Pa-
thology had the largest percentage increase in 1995,
but that followed a year in which it had the largest
Table 1: Median Physician Net Income (in thou-
sands of dollars) after Expenses before Taxes for
Non-Federal Physicians, by Specialty, Employment
Status, and Census Region, 1995.
1995
Percentage
Change
from 1994
All physicians
$160.0
6.7%
Specialty
General/Family practice
124.0
12.7
Internal Medicine
150.0
0.0
Surgery
225.0
2.7
Pediatrics
129.0
17.3
Obstetrics/Gynecology
200.0
9.9
Radiology
230.0
4.5
Psychiatry
124.0
3.3
Anesthesiology
203.0
1.5
Pathology
185.0
21.7
Other
170.0
13.3
Employment Status
Self-employed
199.0
13.1
Employee
136.0
4.6
Independent Contractor
155.0
10.7
Census Region
Northeast
155.0
10.7
North Central
160.0
0.0
South
170.0
6.3
West
160.0
6.7
Source: AMA Socioeconomic Monitoring System 1995
and 1996 core surveys of nonfederal patient care physi-
cians excluding residents.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
decrease.
Managed care contracting increased markedly. In
1995, 83% of physicians had contracts with managed
care organizations, compared with 77% in 1994. Fur-
ther, the share of revenue from those contracts (among
physicians with contracts) declined slightly, from 34%
to 33%. How these events correlate with changes in
net income is a subject of continuing research. It is
safe to say, however, that managed care is not the
only nor necessarily the most important factor affect-
ing income changes from year to year.
Published research suggests that "managed care
has shifted the demand for physician services toward
primary care providers, while reducing utilization, fees,
or both for all physicians." (Simon and Born, "Physi-
cian Earnings in a Changing Managed Care Environ-
ment," Health Affairs, Eall 1996). These findings are
consistent with income patterns by specialty discussed here.
Income tends to vary less across geographic re-
gions than specialties. Nevertheless, some notable
variations occurred for 1994-1995 changes in income.
Increases were highest for physicians in the northeast,
unchanged for those in the central states, and about
average for those in the south and west.
While median net income represents what the
doctor at the 50“" percentile earned, the distribution of
physician income is very wide and many fall far below
that figure. For example, among pediatricians, one-
fourth made $95,000 or less, compared with the me-
dian of $129,000.
Physician Earnings in Context
Physicians typically begin practicing between the
ages of 26 and 35. In 1995, the average age of a medi-
cal school graduate was 28. Counting postgraduate
education, many physicians are in their early thirties
before starting to practice.
Residencies can last up to eight years. Residency
pay is low; the median stipend for 1994-1995 is about
$33,000, and yet residents work an average of 80 to
100 hours per week.
Most physicians incur high educational debt by
the time they begin to practice. Seventy-nine percent
of 1994 graduates reported some level of debt, with
the average for those with indebtedness amounting to
$63,885.
Physicians work longer hours than is typical in
the labor force. The average number of hours spent in
professional activities per week by physicians was 56.7
in 1995, about 42% more than the typical 40-hour week.
About the Survey
Information on medical practices is collected in an
annual survey, the Socioeconomic Monitoring System
(SMS). The survey sample is drawn randomly from
the AMA's Physician Masterfile. Responses are ob-
tained through telephone interviews of approximately
4,000 physicians. The statistics are weighted to adjust
for survey nonresponse bias to improve the precision
of estimates of income for the entire physician popu-
lation. Both office- and hospital-based physicians are
included. Nonmembers of the AMA are included in
addition to AMA member physicians. Specialties are
self-designated. All medical practice information is self-
reported. Self-employeds are full or part owners of
their practices. Net income is defined as income after
expenses before taxes. Income comprises all earnings
from medical practice, including fees, salaries, retain-
ers, bonuses, and deferred compensation.
For the purposes of the SMS, a "physician" is de-
fined as a nonfederal, post-resident MD involved typi-
cally at least 20 hours per week in patient care activi-
ties. Roughly two-thirds of the nation's 720,325 physi-
cians fall into this category. More than 200,000 lower-
earning resident, non-patient-care, federal, and inac-
tive physicians are excluded from these statistics. -
Information provided by the AMA.
Table 2; Mean Physician Net Income (in thousands
of dollars) after Expenses before Taxes for Non-
Federal Physicians, by Specialty, Employment Sta-
tus, and Census Region, 1995.
1995
Percentage
Change
from 1994
All physicians
$195.5
7.2%
Specialty
General/Family practice
131.2
8.3
Internal Medicine
185.7
6.2
Surgery
269.4
5.6
Pediatrics
140.5
11.3
Obstetrics/Gynecology
244.3
21.9
Radiology
244.4
2.9
Psychiatry
137.3
6.8
Anesthesiology
215.1
-1.4
Pathology
209.4
14.7
Other
188.5
19.2
Employment Status
Self-employed
230.8
9.8
Employee
152.6
3.0
Independent Contractor
155.5
-7.7
Census Region
Northeast
192.7
12.6
North Central
194.8
2.9
South
203.7
5.7
West
187.0
8.3
Source: AMA Socioeconomic Monitoring System 1995
and 1996 core surveys of nonfederal patient care physi-
cians excluding residents.
Volume 93, Number 9 - February 1997
437
tJULMJumyuuuMBiuy
AMS Newsmakers
1996-97 Scholarships Awarded to Medical Students
at the University of Arkansas College of Medicine
Joseph Rose (pictured on the left), a junior medi-
cal student of Springdale, is the recipient of
the Class of 1945 Alumni Scholarship. Pictured
on right is Dr. David B. Cheairs of Little Rock.
Doug Dannaway (pictured on the left), a medi-
cal student of Little Rock, has been awarded
the Harold Braswell Memorial Scholarship. Pic-
tured on right is Dr. Richard Wheeler, Assoc. Dean.
Jody Peebles (pictured on the left) of Augusta,
a senior medical student, has been awarded
the Dean's Achievement Scholarship. Pictured
on the right is Dr. Dodd Wilson, Dean.
Kay Kinneman (pictured on the right), a junior
medical student of Little Rock, is the inaugural
recipient of the Class of 1946 Alumni Scholar-
ship. Pictured on the left is Dr. Jim Doherty.
Jody Barboza
(pictured on the
left), a junior
medical student
of Little Rock,
has been named
the recipient of
the Class of 1979
Alumni Scholar-
ship. Pictured
on the right is
Dr. Janet Udouj.
Andrew Martine (pictured on the left), a sopho-
more medical student, is the recipient of the
Robert and Dorothy Bowling Scholarship. Pic-
tured to the right is Dr. Robert Bowling.
438
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Drew Finkbeiner (pictured on the right), a
sophomore medical student of Little Rock, has
been awarded the inaugural Class of 1956 Schol-
arship. Pictured on left is Dr. Arlee E. Pollard.
Huda Sharaf (pictured in the middle), a senior
medical student of North Little Rock, was
awarded the Class of 1968 - Dr. A.J. Thompson
Memorial Scholarship. Pictured on the far left
is Dr. Jack Blackshear and on the far right is
Mrs. Bobbie Blackshear.
Medical students Robert Cullen of Ft. Smith,
Jon Fuller of Little Rock and Tom Van Ffook of
Pine Bluff have been named recipients of South-
ern Medical Association (SMA) Scholarships.
Pictured from left to right are Tom Van Hook;
Robert Cullen; Dr. Michael Mackey, SMA's
Councilor for Arkansas; and Jon Fuller.
Nine medical students have been selected by
the Arkansas Medical Society Alliance to receive
national American Medical Association Educa-
tion and Research Foundation Scholarships. Pic-
tured in the front row from left to right are
Melanie Hoover, senior of Pine Bluff; Megan
Strother, junior of Mountain Home; and Lila
Pappas, senior of Texarkana. Back row left to
right are Mrs. Cathy Mackey, representing the
AMS Alliance; Lolita Palmer, freshman of Little
Rock; Wes Thomas, junior of Fayetteville; David
Oberste, freshman of Little Rock; William
McDonnell, sophomore of Hot Springs; and Eric
Russell, sophomore of Bryant.
Four senior medical students have been awarded
an Use F. Oates Scholarship funded by contri-
butions of the Arkansas Medical Society Alli-
ance (AMSA) county chapters. Pictured from
left to right are Jody Bynum of Dermott; Chad
Braden of Camden; Mrs. Barbi Pierce of the
AMSA; Dr. Reid Pierce; Dichelle Engelkes of
Warren; and Elizabeth Nelson of Carlisle.
Continued on next page...
Send your accomplishments and photo for
consideration in AMS Newsmakers to;
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
j
I
Volume 93, Number 9 - February 1997
439
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PROFESSIONAL INFORMATION
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Medical School: UAMS, 1991
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THOUGHTS & OTHER INFORMATION
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Volume 93, Number 9 - February 1997
443
10 Questions for Your Ho
Choosing a home health care provider can be one
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1
Scientific Article
Socioeconomic Status, Race and Life
Expectancy in Arkansas, 1970-1990
David A. Swanson, Ph.D.*
Mary A. McGehee, M.A.**
Abstract
Earlier research found that high socioeconomic
populations in Arkansas experienced an increase in
mean life expectancy over low socioeconomic popula-
tions between 1970 and 1990. The possibility that these
findings are spurious because of race is tested in this
paper. Using multivariate analysis in conjunction with
estimates of life expectancy by race and socioeconomic
status (SES) we find that between 1970 and 1990: (1)
Black populations with high SES gained more than
three additional years of life expectancy over Black
populations with low SES; and (2) White populations
with high SES gained more than .5 years of life ex-
pectancy over White populations with low SES. These
findings support earlier findings that SES plays an
instrumental role in differential life expectancy. They
also suggest that the effects of SES on life expectancy
are moderated differentially for Blacks and Whites.
Introduction
Significant socioeconomic (SES) effects on changes
in life expectancy at birth were found by Swanson for
Arkansas between 1970 and 1990.’ Specifically, high
SES populations were found to have obtained increased
life expectancy relative to low SES populations. These
findings were in accordance with those reported else-
where and it was argued that declining relative stan-
dards of living for the lower middle and lower SES
populations along with national policies and transfor-
mations in the delivery of healthcare subsequent to
1970 contributed to this finding. However, it may be
the case that these findings are spurious because of
* David A. Swanson, Ph.D., Professor of Urban Studies and
Director of Center for Population Research & Census, School
of Urban & Public Affairs, Portland State University, Oregon.
** Mary A. McGehee, M.A., Graduate Research Assistant,
Department of Rural Sociology, Texas A & M Univeristy,
College Station, Texas.
race. Blacks, who have lower life expectancy than
Whites at national and state levels also tend to have
lower SES, on average, than Whites.^'’ In this paper,
we examine the possibility that the SES effects found
earlier were spurious by comparing life expectancy
changes between 1970 and 1990 for high and low SES
populations separately by race. If no significant SES
difference exists separately for Blacks and Whites then
the earlier argument concerning SES effects would be
fallacious. If, however, an SES differential persists for
Blacks and Whites separately, the earlier finding would
be supported.
Methods And Data
For the same reasons described in the earlier pa-
per by Swanson, we use a regression-based technique
to estimate life expectancy. '* The model used is:
e(,= {82.276 - (4.24*CDR) + (3.02*ln(P65+)) + (.0267^CDR-)
+ (.1773=^Ln(P65+)^) + (.8707’’[(CDR)=^(Ln(P65+))])
e^is life expectancy at birth
CDR is the Crude Death Rate
L7i(P65+) is the natural base logarithn of the perceixt of
the population aged 65 years and over
As was the case in the earlier study the analytical
unit is a county population, although we divide these
populations by race. White and Black. Likewise, data
needed to estimate life expectancy by race and county
were taken from vital statistics reports and census re-
ports for 1970 and 1990, respectively.'^'^ County popu-
lations by race are grouped into two sets for 1970 and
1990: (1) high SES, the 1st quintile, the 20% of the
state's counties with the lowest percent of persons in
poverty, by race; and (2) low SES, the 5th quintile, the
20% of the state's counties with the highest percent of
persons in poverty, by race. For whites, all 75 counties
Volume 93, Number 9 - February 1997
445
Table 1. Life Expectancy For 1970 County Populations
By Race/SES Group
Low SES Populations* High SES Populations*
Black
White
Black
White
Woodruff (71)
Stone(75)
Pulaski(66)
Howard(73)
Monroe(71)
Newton(73)
Dallas(74)
Miller(71)
Chicot(74)
Fulton(77)
Hot Spring(68)
Washington(73)
Phillips(71)
Searcy(76)
Faulkner(70)
Phillips(73)
Poinsett(76)
Perry(70)
Miller(65)
Little River(74)
Crittenden(69)
Cleburne(75)
Clark(72)
Faulkner(74)
Mississippi(67)
Clay(73)
White(72)
Quachita(71)
Desha(71)
Madison(69)
Howard(72)
Ashley(71)
Van Buren(75)
Sebastian(73)
Randolph(76)
Crittenden(70)
Lawrence(73)
Union(72)
Marion(77)
Saline(74)
Montgomery(74)
Columbia(75)
Scott(75)
Jefferson(71)
Izard(72)
Pulaski(72)
* Each county is listed in descending order by percent of persons in poverty for
the Race/SES group in question, with life expectancy at birth shown m parentheses.
in the state are used. Thus, the 1st quintile for Whites
is comprised of the 15 counties with the lowest per-
cent of White persons in poverty; and the 5th quintile
for Whites is comprised of the 15 counties with the
highest percent of White persons in poverty. Because
of small numbers, only 40 of the state's 75 counties are
used for the Black population. Thus, the 1st quintile
for Blacks is comprised of the 8 counties with the
lowest percent of Black persons in poverty; and the
5th quintile for Blacks is comprised of the 8 counties
with the highest percent of Black persons in poverty.
To measure change in life expectancy between 1970
and 1990 we construct a dummy variable regression
model for each of the four race/SES groups:
0^1990 = a + b(Yr)
e^l990 is life expectancy in 1990 for a given! race! SES
group as found from the equation shown above
a is the mean life expectancy for the same race/SES group
in 1970 as found from the equation shown above
b is the change in life expectancy between 1970 and 1990
for the race/SES group in question
YR is a dummy variable for year (YR = 0, in 1970; YR-1,
in 1990)
The one-tailed test (p = .05) is applied to the slope
coefficient, b, in each of the four equations to deter-
mine if there is a statistically significant change in life
expectancy for the race/SES group in question between
1970 and 1990. Because there is a positive correlation
between life expectancy for a given race/SES group in
446
1970 and 1990, the standard error is
diminished. ITowever, this effect is
mediated by the extremely small
sample sizes and the net result is
that a given t-test is not highly sub-
ject to a Type I error (rejecting a
true null hypothesis). The null hy-
pothesis is that there is no change
(i.e., b = 0); the alternative hypoth-
esis is that there is positive change
(i.e., b >0). This test structure is
appropriate because there is evi-
dence to indicate that, on average,
life expectancy increased between
1970 and 1990E If a given slope
coefficient is found to be statistically
significant then we reject the null
hypothesis that b=0 and assume the
value of b found in the equation rep-
resents the amount of change in life
expectancy that occurred for the
race/SES group in question between
1970 and 1990. If a given slope co-
efficient is not found to be statisti-
cally significant, then we do not reject the null hy-
pothesis and assume that the value of b is zero - there
was no change in life expectancy for the group in ques-
tion between 1970 and 1990.
Results and Discussion
The estimated life expectancy values for each of
the four race/SES groups in 1970, by county, are given
in Table 1. The corresponding 1990 life expectancy val-
ues are found in Table 2. Table 3 provides the four
dummy variable regression equations that were con-
structed using the life expectancy values in tables 1
and 2. The dummy variable regression equations
clearly show that within each of the two racial groups,
high SES populations posted relative gains in life ex-
pectancy over low SES populations between 1970 and
1990. For Whites, the high SES populations gained,
on average, 2.96 years in life expectancy while the low
SES white populations gained on average only 2.28.
For Blacks, the high SES populations gained, on aver-
age, 3.42 years of life expectancy between 1970 and
1990 while the low SES populations showed no gain,
on average, and, in fact, may have lost years.
In general, the results reported here suggest that
that the findings reported earlier were not spurious
and that high SES populations experienced relative
gains in life expectancy over low SES populations, not
only overall, but by race. However, it also appears
that the impact of low SES is different for Whites and
Blacks. Low SES White populations appeared to have
gained additional years of life expectancy between 1970
and 1990, although not as much as either the high SES
White or the high SES Black populations. For the low
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
SES Black population, however, there appears to be
no increase whatsoever in life expectancy during this
same twenty-year period.
Acknowledgment
An earlier version of this paper was presented at the
1995 Annual Meeting of the Southwestern Sociological As-
sociation, March 22nd-23rd, Dallas, Texas. We are grateful
for comments provided by Doug Murray, Dudley Poston,
and Kenneth Hinze.
References
1. Swanson, DA. The Relationship Between Life Expectancy
and Socioeconomic Status in Arkansas: 1970 and 1990. Jour-
nal of The Arkansas Medical Society, 1992; 89(7):333-335.
2. National Center For Health Statistics U.S. Decennial Life
Tables For 1979-81, Vol 1, no. 1, United States Life Tables.
U.S. Department of Health and Human Services, 1985;
Hyattsville, Maryland.
3. McGehee, MA. Black/White Life Expectancy Differences
and Sociodemographics: Arkansas and The U.S. Journal of
The Arkansas Medical Society, 1994; 91(4):177-180.
4. Swanson, DA and EG Stockwell. Are Geographic Effects
On Life Expectancy in Ohio Spurious Because of Race? Ohio
Journal of Science, 1988; 88(3):116-118.
5. Arkansas Department of Health (1970, 1990) Arkansas Vital
Statistics, Center For health Statistics. Little Rock: Arkansas
Department of Health.
6. U.S. Bureau of The Census (1970, 1990) General Popula-
tion Characteristics, Arkansas. Washington D.C.: Govern-
ment Printing Office.
Table 2. Life Expectancy For 1990 County Populations
By Race/SES Group
Low SES Populations*
High SES
Populations*
Black
White
Black
White
Lee(72)
Searcy(76)
Hot Spring(71)
Faulkner(76)
Lafayette(70)
Newton(78)
Little River(75)
Lonoke(75)
Phillips(68)
Fulton(78)
Calhoun(71)
Dallas(76)
Chicot(73)
Stone(77)
Craighead(77)
Ashley(74)
St. Francis(71)
Lawrence(76)
Pulaski(71)
Union(75)
Woodruff(70)
Lee(73)
Sebastian(79)
Sebastian(75)
Desha(71)
Woodruff(73)
Conway(70)
Columbia(76)
Monroe(68)
Montgomery(77)
Faulkner(74)
Jefferson(74)
Poinsett(73)
Quachita(75)
Jackson(75)
Calhoun(74)
Van Buren(80)
Nevada(75)
Monroe(76)
Crittenden(76)
Sharp(80)
Benton(78)
Scott(76)
Saline(76)
Clay(75)
Pulaski(75)
* Each county is listed in descending order by percent of persons in poverty for
the Race/SES group in question, with life expectancy at birth shown in parentheses.
Table 3. Dummy Regression and Statistical Test Results: Changes in Life
Expectancy, By Race/SES Group, Between 1970 and 1990
standard
t value
Decision
a
b
error of b
(b=0)
P(b=0)
Ho: b-0
Black
High SES
70.04
3.42
1.58
2.17
.048
reject Ho
adj. R^= .20
Low SES
71.14
-0.74
1.16
-0.63
.537
do not reject Ho
adj. R^=.03
White
High SES
72.45
2.96
0.48
6.16
.00001
reject Ho
adj. R2=.58
Low SES
73.89
2.28
0.80
2.86
.0079
reject Ho
adj. R^=.23
Volume 93, Number 9 - February 1997
447
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Special Article
Physician Training for Specialist to
Generalist Career Change
George M. Finley, M.D.*
Rebecca Hyatt, B.S., C.P.M.’^*
The end of calendar year 1996 marked a milestone
in the lives and careers of two Arkansas physicians,
Drs. George Garrett and Dan Moser. The
board-certified specialists, in Obstetrics/Gynecology
and Pathology, respectively, completed Family Prac-
tice Residency training at Area Health Education Cen-
ter - Southwest, affiliated with the University of Ar-
kansas for Medical Sciences, in Texarkana, Arkansas.
Drs. Garrett and Moser are part of a small but grow-
ing number of physician specialists who are respond-
ing to the changing health care delivery system with
mid-career changes and seeking appropriate training
in family practice.
Background
Sky-high rates of increase in the cost of health care
in the 1980s and early 1990s provided incentive to ex-
amine our health care delivery system and find ways
to lower the rates of increase in health care costs. The
healthcare challenge of the decade is to lower those
costs while keeping the decrease in beneficial outcomes,
technical quality, access, and service to the barest mini-
mum.’
One key to the cost containment effort is the
gatekeeper role of the primary care provider who au-
thorizes access to diagnostic services, referrals to spe-
cialists, emergency, and hospital care.’ In the United
States the ratio of specialists to generalists is approxi-
mately 2:1. Just the opposite is true in most industrial-
ized nations. Often cited in medical policy reports are
the shortage of primary care physicians, oversupply
of medical and surgical subspecialists, and the lack of
sufficient health care providers of any type in inner-city
and rural areas of the United States.^ ”
Significant proposals have been recommended to
* George M. Finley, M.D., is Executive Director and Residency
Director of AHEC-SW and Assistant Professor with the De-
partment of Family and Community Medicine, UAMS.
** Rebecca Hyatt, B.S., C.P.M., is Director of Development and
Research at AHEC-SW in Texarkana.
George Garrett, M.D.
change the maldistribution of physicians. In 1992, the
Council on Graduate Medical Education recommended
reform of graduate medical education such that at least
50% of the physicians trained in the U.S. would be
generalists.'* ** This proposal was supported by the Phy-
sician Payment Review Commission, the American
Academy of Eamily Physicians, the American College
of Physicians, the Accreditation Council for Graduate
Medical Education, and the Association of American
Medical Colleges.'*
However, the current medical education system,
by itself, cannot solve the short-term need for physi-
cians. If 70% of medical school graduates went into
primary care, the 50:50 ratio would not be reached till
the year 2020.’’
The demand for primary care physicians is increas-
ing proportionately to the spread of managed care and
health maintenance organizations which depend on
an adequate primary care workforce as the cornerstone
of vertically integrated, cost-effective care. One
short-term solution to this supply/demand dilemma is
retraining the specialist or career change education.®-^
National Overview
In 1966, a pilot project at the Pacific Medical Cen-
ter in San Erancisco was the first physician retraining
program in the United States. It was a 6- to 12-month
program and resembled a mini-internship. In 1969, a
retraining program at the Medical College of Penn-
sylvania was designed to address retraining needs of
Dan Moser, M.D.
Volume 93, Number 9 - February 1997
449
Figure 1:
Specialists Retraining
in Family Practice
in 4-State Region
Resident
Specialists
#FP
Positions
Re-training
State
Residencies
1995-96
since 1994
Arkansas
7
134
4
Oklahoma
6
128
1
Louisiana
7
95
1
Texas
25
616
6
TOTAL
45
973
12
Figure 2; Specialists Type Re-traii^i"*^
Specialty
Anesthesiology
ER Medicine
OB/GYN
Number
2
1
2
Oncology 1
Ophthalmology 1
Otorhinolaryngology 1
Pathology 3
Surgery 1
clinically inactive physicians who wished to return to
clinical practice. The 9-month program was eventu-
ally reduced to 8 weeks.®- ^
In a 1993 survey of 46 California Managed Care
Organizations to explore their interest in retraining
specialists, 29 MCOs responded. Two were sponsor-
ing retraining programs and seven were planning to
initiate programs.®
One of the respondents. Sharp Health Care in San
Diego, began retraining in 1994 at the request of its
OB/GYNs. The 10-month part-time curriculum includes
family medicine preceptorship and standardized pa-
tient assessments. Also in San Diego, the Mercy Phy-
sicians Medical Group initiated an eighteen-month
part-time retraining program for its internal medicine
subspecialists in 1993.®-’
None of the programs named above are eligible
for board certification in family practice.
A few medical schools offer retraining using exist-
ing programs, such as the College of Medicine at the
University of Tennessee at Memphis. It's 15-year-old
program is a 3-year residency leading to family prac-
tice certification. Six to eight physicians participate each
year.^
Regional Survey
Neither the American Medical Association nor the
American Academy of Family Practice have data on
the number of specialists seeking Family Practice Resi-
dency training. A literature search did not produce
that data either.
AHEC-SW staff conducted a telephone survey of
all the family practice residency programs in our 4-state
area of Texas, Oklahoma, Ar-
kansas, and Louisiana. (See
Figures 1 & 2). Since 1994 the
residencies have trained 12
specialists in family practice.
Their specialties were varied.
We think other regions of the
country may have a higher
rate of specialists in family
practice training due to the
fact that the 4 states in this
survey are in the infancy stage
of managed care health delivery and some other states
are in more advanced stages. Nevertheless, the fig-
ures indicate only a small number of physicians have
opted to obtain generalist training in a family practice
residency.
Two Physicians' Experiences with
Re-Training
Drs. George Garrett and Dan Moser were inter-
viewed regarding their decision to enter a family prac-
tice residency training program, their experience, and
their perspective at the end of the training period.
Dr. Moser completed medical school at the Uni-
versity of Texas Southwest Medical School in Dallas, a
one-year internship in Internal Medicine at the Uni-
versity of Arkansas for Medical Sciences, and became
board-certified in pathology in 1974. He was appointed
Director of Pathology at Wadley Regional Medical Cen-
ter in Texarkana in 1975. More recently he worked as
locum tenens for other pathologists in Texas and Ar-
kansas. In 1992, he recognized that the health care
delivery environment was changing and that he needed
to re-direct his efforts. The AHEC-SW residency pro-
gram began in July 1993 and correlated with his inter-
est in making a career change. Dr. Moser said he had
always enjoyed seeing patients, and he was encour-
aged by the AHEC Director, faculty, and residents to
enter the program. He was accepted and given six
months credit.
In retrospect. Dr. Moser is glad he made the deci-
sion to retrain. He would not underestimate the stress
and strain of residency training, especially the first
year. He had to adjust to carrying a beeper and work-
ing long hours. He said the younger residents' enthu-
siasm helped him to keep his goal alive and his inter-
action with them added a sparkle to the process.
Dr. Moser would recommend family practice train-
ing to specialists if the physician's health is good; he/
she really wants to do it; and he/she really enjoys pa-
tients. Dr. Moser said, with a grin, "I'd do it again,
but I might think a little longer!"
Dr. Moser is being recruited by several entities and
is in the process of deciding which one he will accept.
Dr. Garrett completed medical school at the Uni-
versity of Arkansas for Medical Sciences and finished
a residency in Obstetrics and Gynecology at Louisiana
450
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
State University. He maintained a private practice for
15 years in Hope, Arkansas (Population: 10,000) which
is 30 miles from Texarkana.
Dr. Garrett said that it was difficult to maintain an
OB practice in a small town, and when his partner left
in 1991, it became even more difficult. He was already
accustomed to some degree of family practice in his
OB/GYN work and he always liked that aspect. Dr.
Garrett said his family was very supportive of his de-
cision to enter residency training and he could not
have completed it without their support.
Dr. Garrett was given 12 months credit when he
was accepted into the program. He also is glad that he
completed the family practice training. His advice to
specialists considering generalist training is to care-
fully think through his/her goals and be prepared to
redirect his/her efforts.
Dr. Garrett expects to practice either in Hope or
Texarkana or maybe both!
Conclusions
Market forces are already shifting physicians into
primary care. An oversupply of medical and surgical
specialists is a puzzling problem in U.S. health care
today. “ Programs for retraining specialists as primary
care physicians are warranted and the demand for such
programs is likely to increase. New models for retraining
are in their early stages, but at present, residency train-
ing remains the standard for primary care competence.
References
1. Gabriel SE. Primary care: specialists or generalists. Mayo
Clin Proc 1996; 71:415-419
2. Colwill JM. Where have all the primary applicants gone.
N Engl J Med 1992;326:387-393
3. Politzer RM, Harris DL, Gaston MH, Mullan F. Primary
care physician supply and the medically underserved. JAMA
1991;266: 104-109
4. Council on Graduate Medical Education. Third report:
improving access to health care through physician workforce
reform: directions for the 21st century. 1992. Washington DC:
Department of Health and Human Services
5. Wall EM, Saultz JW. Retraining the subspecialist for a pri-
mary care career: four possible pathways. Acad Med
1994;69:261-266
6. Kahn BK, Graham R, Schmittling G. Entry of US Medical
School Graduates into family practice residencies: 1992-93
and 3-year summary. Earn Med 1993; 25:502-10
7. Villaneuva AM, White BG, Donahue GD. A quarter-century
of experience with career change education: an option for
turning specialists into generalists. Acad Med
1995;70:5110-5116
8. Seifer SD, Leslie J, Stoddard JJ, Troupin B, O'Neil EH.
Retraining nongeneralists to provide primary care. Acad Med
1995;70:854-855
9. Montague J. Back to school. Hosp & Health Net 1993;0ct 5:49-52
lO.Scherger JE. Retraining specialists for primary care. Hosp
Prac 1995; Nov 15:24D - 24H
Freemyer Collection System, Inc.
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Volume 93, Number 9 - February 1997
451
Loss Prevention
Defensible Case Made Indefensible
J. Kelley Avery, M.DA
Case Report
A 17-year-old boy who had been autistic since birth
and who had a lifelong history of seizures that proved
very difficult to control had been followed all his life
by the same physician, with frequent help from a neu-
rologist who had also been involved with the patient
for a long time. Even with maintenance anti-seizure
medication using combination therapy, seizure activ-
ity occasionally required IV sedation to interrupt the
attack.
During an unwitnessed seizure, the patient ap-
parently fell and was in considerable pain. The emer-
gency medical service was notified, and on the initial
evaluation before transport found reflexes in the ex-
tremities to be "positive," but the patient would gri-
mace and moan when moved. He was therefore trans-
ported on a backboard with a cervical collar and a chin
immobilizer. He was seen in the emergency depart-
ment (ED) by his regular primary care physician who,
after a difficult evaluation, concluded that there were
no apparent focal neurologic deficits but that there was
evidence of significant and unlocalized discomfort in
the patient's neck.
X-rays of the spine were ordered, and both lum-
bar and cervical films were viewed by the radiologist
and the attending physician. The radiologist reported
that the films were negative. The mother was given
extensive instructions on the care of her son and ad-
vised to return to the ED or to the physician's office
for reevaluation at any time. The attending physician
did document in his office record that he received a
phone call from the mother two hours after the patient's
discharge from the ED informing him that the patient
had had two seizures before leaving the ED and three
* Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Co., Brentwood, TN. This
article appeared in the Journal of the Tennessee Medical Associa-
tion. It is reprinted here with permission.
452
more after arriving home. Again, the mother was ad-
vised to bring the patient in for reevaluation, but she
declined because she could see no change in her son's
condition after the seizures. It is well to note that the
mother had taken care of this patient for his entire life
and consequently must have become accustomed to
all kinds of unexpected behavior.
The following morning, on routine review of the
films taken at night in the ED, the senior radiologist
reported that the films were non-diagnostic because
there was no visualization of C-7 on any of the views.
Before this report could be acted upon by the attend-
ing physician, the patient was brought to the ED about
noon, unable to move his lower extremities, and hav-
ing not urinated since the last seizure the night be-
fore. The presumptive diagnosis at this point was spi-
nal cord injury, and the patient was transferred to the
care of a neurosurgeon in the medical center.
On CT scanning of the neck no fracture was seen,
but there was a "2mm" forward subluxation of C-7 on
T-1. An emergency exploration of this area with a pos-
terior spinal fusion was done, and after a prolonged
and complicated hospitalization, the patient was trans-
ferred to a long-term care facility because continued
care at home was not possible.
Because of the very serious injury and the devas-
tating neurologic deficit, a multi-million dollar lawsuit
was filed, charging both the attending physician and
the radiologist with negligence in "carelessly" failing
to clear the cervical spine and "carelessly" failing to
get appropriate consultations. The attending physi-
cian was charged with "carelessly" failing to admit the
patient to the hospital for observation and appropriate
monitoring during the night.
Loss Prevention Comments
Failure to adequately evaluate the cervical spine
after trauma of any kind is one of those claims almost
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
automatically considered medical malpractice when a
less-than-desirable outcome follows; in addition, spi-
nal cord injuries that result in a significant neurologic
deficit are among the most expensive. Lifelong care is
necessitated by the deficit and usually must be carried
out in a long-term facility of some kind, with the par-
ticipation of various paramedical disciplines.
Although there were obvious problems in defend-
ing this suit, e.g., the failure to get x-ray views of the
entire cervical spine, there were circumstances that
should have mitigated the damages to some degree.
The seizures, which were in all probability respon-
sible to some degree for the neurologic damage, were
not the fault of the physicians involved. The mother's
failure to avail herself of the offered reevaluation after
the post-discharge seizures occurred was not the fault
of the physicians. The attending physician had given
the mother good detailed instructions in the care of
the patient, and had described in detail the signs to
look for that would indicate the need for reevaluation.
There was the prompt review of the films in the radi-
ology department, which had discovered the error.
Much time and compassionate concern had been in-
vested by the attending physician in the evaluation of
his patient. Nobody is perfect! This is generally un-
derstood by a jury when this kind of prompt discov-
ery of the error is in evidence.
One thing in this case, however, made the dan-
gers of trial too great to consider. The physicians
blamed each other for the outcome. This injury was
serious, the evaluation of the injury was less than per-
fect, there was great sympathy for this unfortunate
patient and his mother, and the monetary damages
were calculated to be in seven figures. Nonetheless,
not even all this made this case demand settlement.
When physicians blame each other in such a situa-
tion, where each has some obvious responsibility, we
lose everything we have going for us. The settlement
required here was almost in the seven-figure range.
The lessons? Viezu all the vertebrae! Don't blame each other!
Emergency Medicine Opportunities
C/)
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Full-Time Opportunities available in:
Van Buren
Crawford Memorial Hospital is a modem, 103-
bed facility with an annual ED volume of 14,000.
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For more information on these and other
opportunities in Arkansas please contact:
Tom Kubiak 800-325-2716 or
FAX CV to Tom at 314-919-8920.
Do You Know What
is Going on in the
81st Session of the
Arkansas General
Assembly?
As you do know, we are in the midst of a legisla-
tive session - legislation that may greatly affect
you as a physician.
What you may not know is that as a member of
the Arkansas Medical Society you have the
benefit of staying abreast of legislative issues on
a weekly basis.
How? Well, the AMS compiles pertinent infor-
mation for you into a bulletin titled Legislative
Update. This bulletin is then mailed to your home
address each week during the legislative session.
The bulletin also lists the 1997 legislators with
their addresses and phone numbers. So, if you
would like, you can take an active role in legisla-
tion that affects you.
If you are not a member and would like to
subscribe, call 1-800-542-1058.
If you are a member, watch your mail for the
AMS Legislative Update Bulletin! Then you will
know what is going on in the 81st Session of the
Arkansas General Assembly.
FOR SALE
Leisegang LM-7 Flexible Hysteroscopy
System, complete with camera and video
monitor. Excellent condition.
Call 501-741-2229
Volume 93, Number 9 - February 1997
453
Cardiology Commentary and Update
J. David Talley, M.D.*
Vascular Health: The Emerging
Advances in basic and clinical investigation point
to the endothelium as a link between pathological pro-
cesses and clinical events in the pathogenesis of acute
ischemic coronary syndromes. Diagnostic methods
have been refined to evaluate endothelial function.
Acetylcholine infused directly into a normal coronary
artery causes vasodilatation. Failure to diliate or "para-
doxical vasoconstriction" is seen with acetylcholine
infused into atherosclerotic arteries. Promising thera-
pies for restoring proper endothelial function include
the use of 3-Hydroxy-3-MethylGlutarylCoenzyme A
(HMG Co-A) reductase inhibitors and Angiotensin-
Converting Enzyme (ACE) inhibitors.
HMG Co-A Reductase Inhibitors. Dietary and
pharmacological therapy aimed to treat dyslipidemia
have been subjected to detailed angiographic analy-
sis. These trials have shown that lipid lowering therapy
may slow atherosclerotic progression and in some pa-
tients may actually promote regression.’ However,
these angiographic studies show that the effect on
plaque volume is minimal, with only a 2 - 5% decrease
in plaque size (Figure 1). Nonetheless, these appar-
ently insignificant angiographic changes are accompa-
nied by dramatic reduction in the incidence of clinical
coronary syndromes. This reduction in acute coronary
syndromes is out of proportion to the degree of regression
and raises the question as to the mechanism of action.
HMG-CoA reductase inhibitors effectively reduce
plasma cholesterol levels by interfering with the
rate-limiting step in the cholesterol biosynthetic path-
way.^ Landmark primary and secondary prevention
trials using HMG-CoA reductase inhibitors show that
reducing low density lipoprotein (LDL) decreases car-
diovascular deaths and mortality of all causes. This
improved clinical outcome may be due to restoration
* Dr. Talley is with the Division of Cardiology, Department of
Internal Medicine, UAMS Medical Center.
Appreciation of the Endothelium
of normal endothelial function.^' ^
HMG-CoA reductase inhibitors have become pro-
gressively more potent in their ability to reduce LDL.
The enhanced potency is related to tissue specificity,
onset of action, longer half-life, and activity of me-
tabolites. These agents may possess unique proper-
ties related to their ability to alter hematological pa-
rameters, adhesion molecules, and non-lipid param-
eters such as plasma viscosity. Clinical trials are on
the drawing board to determine the additional benefit
of these agents compared to standard medical man-
agement for unstable angina pectoris. Interestingly,
two clinical trials, AVERT (Atorvastatin Vs.
rERascularization Trial) and SMART (Specialized Medi-
cation And Revascularization Therapy) have been de-
signed to compare the efficacy of reductase inhibitors
in patients treated with medical management alone
compared to those treated with medical management
and percutaneous transluminal coronary angioplasty.
ACE Inhibitors. An intriguing finding from the
Survival and Ventricular Enlargement (SAVE) and Stud-
ies of Left Ventricular Dysfunction (SOLVD) trials was
the unanticipated result of fewer ischemic events and
the need for revascularization procedures in patients
who received an AGE inhibitor.^ The mechanism for
this reduction was evaluated in the Trial on Reversing
Endothelial Dysfunction (TREND) study. In normal
endothelium, tissue ACE and other components of the
reninangiotensin system mediate vasoconstriction
counterbalanced by nitric oxide which causes vasodi-
latation. Endothelium damaged by atherosclerosis loses
its ability to vasodilate leading to unopposed vasocon-
striction. Quinapril (Parke-Davis, Morris Plains, NJ,
USA) is a new ACE inhibitor with high binding affin-
ity to tissue ACE, and therefore offers the theoretical
promise of restoring "balanced" endothelial vasoac-
tivity by inhibiting the vasoconstrictive effects of tissue
454
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
100
■ Reduction in Stenosis
FATS-1 FATS-2 STARS
Figure 1: There is a marked discrepancy between the degree of angiographic regression in various trials and the marked
reduction in clinical events with the use of lipid lowering agents. This finding suggests that the endothelium plays a vital role
in reversing endothelial dysfunction.
Abbreviations: FATS-1 = Familial Atherosclerosis Treatment Study (nicotinic acid + colestipol; FATS-2 = Familial Atherosclero-
sis Treatment Study (lovastatin + colestipol); STARS = St, Thomas' Atherosclerosis Regression Trial (diet + resin)
ACE. The TREND study showed that quinapril re-
versed endothelial dysfunction.” Two studies are cur-
rently ongoing to determine if this angiographically
documented finding leads to an improvement in clini-
cal outcome. The Quinapril Antiischemia and Symp-
toms of Angina Reduction (QUASAR) trial is a
double-blind, placebo-controlled trial of 350 patients
with a primary endpoint of the number and duration
of ischemic episodes on 48 hour ambulatory electro-
cardiogram. The Quinapril Ischemic Event Trial
(QUIET) study, in progress for several years now, is a
double-blind, placebo-controlled trial which will evalu-
ate the occurrence of clinical ischemia. There are sev-
eral additional trials of ACE inhibitors for treatment of
coronary artery disease in patients with normal left
ventricular systolic function.®
The finding that endothelial dysfunction can be
reversed using HMG-CoA reductase inhibitors and
ACE inhibitors point to the key role of mediators in
regulating vascular health. It remains to be defined if
these angiographic findings are linked to improved
clinical outcome.
References
1. Rossouw JE. Lipid-lowering interventions in angiographic
trials. Am J Cardiol 1995;76:86C-92C.
2. Nawrocki JW, Weiss SR, Davidson MH, et al. Reduction
of LDL cholesterol by 25% to 60% in patients with primary
hypercholesterolemia by atorvastatin, a new HMG-CoA re-
ductase inhibitor. Arterioschler Thromb Vase Biol 1995;15:678-682.
3. Scandinavian Simvastatin Survival Study Group. Random-
ized trial of cholesterol lowering in 4444 patients with coro-
nary heart disease: the Scandinavian Simvastatin Survival
Study (4S). Lancet 1994;344:1 182-1 186.
4. Sacks FM, Pfeffer MA, Moye LA, for the Cholesterol and
Recurrent Events Trial Investigators. The effect of pravastatin
on coronary events after myocardial infarction in patients
with average cholesterol levels. N Engl J Med
1996;335:1001-1009.
5. Treasure CB, Klein JL, Weintraub SW, et al. Beneficial
effects of aggressive lipid lowering therapy on the coronary
endothelium in patients with coronary atherosclerosis. N
Engl J Med 1995;332:481-487.
6. Anderson TJ, Meredith IT, Yeung AC, et al. The effect of
cholesterol lowering and antioxidant therapy on
endothelium-dependent coronary vasomotion. N Engl J Med
1995;332:481-487.
7. Lonn EM, Yusuf S, Jha P, et al. Emerging role of
angiotensin-converting enzyme inhibitors in cardiac and vas-
cular protection. Circulation 1994;90:2056-2069.
8. Mancini GBJ, Henry GC, Macaya C. et al.
Angiotensin-converting enzyme inhibition with quinapril
improves endothelial vasomotor dysfunction in patients with
coronary artery disease. The TREND (Trial on Reversing
ENdothelial Dysfunction) study. Circulation 1996;94:258-265.
9. Pepine CJ. Ongoing clinical trials of angiotensin-converting
enzyme inhibitors for treatment of coronary artery disease
in patients with preserved left ventricular function. J Am
Coll Cardiol 1996;27:1048-1052.
Volume 93, Number 9 - February 1997
455
Information provided by the Arkansas Department of Health, Division of Epidemiology
The American Public Health Association Calls for
Curtailment of PVC Use in Health Care Facilities
At the November annual meeting of the American
Public Health Association (APHA), a resolution was
passed that called for health care facilities to cut back
and eventually eliminate the use of polyvinyl
chloride(PVC) plastic. PVC makes up about 25% of
the hospital plastics stream predominately in the form
of blood bags. The resolution is a response to the
continued concerns about dioxin formation and release
when hard plastics are incinerated. The resolution
cites the EPA Dioxin Reassessment which states that
medical waste disposal is a major source of dioxin con-
tamination. The resolution also cited an earlier APHA
resolution that stated that virtually all chlorinated or-
ganic compounds exhibit at least one of a wide range
of serious toxic effects. The resolution was originated
by Peter Orris an M.D. and professor of occupational
medicine at the University of Illinois, Chicago. Dr.
Orris is also a member of the group. Physicians for
Social Responsibility.
The resolution urges all health care facilities and
health care professionals to explore ways to reduce or
eliminate their use of PVC plastics. It urges medical
suppliers to develop, produce, and bring to market
appropriate, cost-competitive products that can replace
those that contain PVC or other chlorinated plastics.
The resolution also encourages government oversight
agencies and private accrediting bodies to incorporate
requirements in their certification standards for health
care institutions to reduce toxic pollutants.
The resolution is very controversial and has drawn
criticism from the plastic industry and the American
Hospital Association. Both contend that the resolu-
tion would result in little to no decrease in dioxin
emissions while significantly increasing health costs.
They also contend that the proposal is based on out-
dated EPA data. EPA has recently revised its estimate
of dioxin emissions from medical waste incinerators
and the incinerators are not now considered to be a
primary source of dioxin in the environment. The
American Society of Engineers conducted a study
which concluded that there is no link between the
amount of chlorinated plastics burned to the amount
of dioxin produced. The Vinyl Institute stated that
the resolution was not grounded in science and would
not do anything for the environment. The critics sum-
marized that instead of pinpointing PVC as the prob-
lem, APHA should focus on encouraging practices that
reduce regulated medical waste production in hospi-
tals through improved medical waste management.
Influenza Update
Arkansas - Through early January 1997, the Ar-
kansas Department of Health (ADH) has obtained eight
positive influenza cultures from Arkansas, Garland,
Greene and Pulaski counties. All are type A (subtype
unknown). To date, there have been no reports of
influenza outbreaks in Arkansas.
United States - For the week ending December 28,
1996, influenza activity, as assessed by state and terri-
torial epidemiologists, was reported as widespread
in 17 states. Regional activity was reported in 16 states
and twelve states, including Arkansas, reported sporadic
activity. Five states did not report.
From September 15 through December 28, 1996,
the U.S. World Health Organization's collaborating
laboratories tested 14,893 specimens for respiratory vi-
ruses and 2,266 (15%) have been positive for influenza.
Of these, 2,237 (99%) were identified as influenza type
A and 29 (1%) as influenza type B.
For more information on influenza or to report
outbreaks, call the ADH Division of Communicable
Disease & Immunization at (501)661-2784 or the Com-
municable Disease Reporting System at (800)482-8888.
456 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reported Cases of Selected Diseases in Arkansas
Profile for November 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
Nov. 1996
Total
Reported
Cases
YTD1996
Total
Reported
Cases
YTD1995
Total
Reported
Cases
1995
Total
Reported
Cases
YTD 1994
Total
Reported
Cases
1994
Campylobacteriosis
16
229
140
153
175
187
Giardiasis
13
163
125
131
115
126
Shigellosis
38
156
130
176
182
193
Salmonellosis
27
432
317
332
517
534
Hepatitis A
47
474
599
663
242
253
Hepatitis B
4
75
72
83
53
60
HIB
0
0
6
6
5
5
Meningococcal Infections
2
31
33
39
49
55
Viral Meningitis
2
32
32
31
61
62
Lyme Disease
0
25
11
11
15
15
Rocky Mountain Spotted Fever
1
22
31
31
18
18
Tularemia
0
19
20
22
22
23
Measles
0
0
2
2
1
5
Mumps
0
1
6
5
6
7
Gonorrhea
355
4724
5502
5437
6479
7078
Syphilis
46
691
980
1017
1005
1096
Legionellosis
0
1
6
5
15
16
Pertussis
0
10
59
59
33
33
Tuberculosis
18
183
212
271
223
264
For a listing of reportable diseases in Arkansas, call the Arkansas Department of Health, Division of
Epidemiology, at (501) 661-2893 during normal business hours.
Do the Write** Thing!
We're always looking for interesting and informative
articles for The Journal. If you have a topic that you
think would be of interest to your peers, please submit it
for consideration to:
Managing Editor
The Journal of the Arkansas Medical Society
P.O. Box 55088
Little Rock, AR 72215-5088
(501)224-8967 (800)542-1058
SUPPORT YOUR ADVERTISERS
Many of the advertisers in this Journal are long-
standing patrons of our monthly publication.
Don't take them for granted. Read their adver-
tisements. If you call on them for their prod-
ucts and/or services, let them know you read
about them in The Journal of the Arkansas
Medical Society.
Volume 93, Number 9 - February 1997
457
New Members
DARDANELLE
Hartman, Ray, General Surgery. Medical Educa-
tion, Dalhousie, Halifax, Nova Scotia, 1984. Internship,
Dalhousie, 1985.
FORT SMITH
Haraway, Stuart D., Obstetrics/Gynecology. Medi-
cal Education, University of Oklahoma, Oklahoma
City, 1989. Internship/Residency, Oklahoma Memo-
rial Hospital, 1990/1993. Board certified.
Patrick, Donald Lee, Cardiovascular & Thoracic
Surgery. Medical Education, University of Elorida,
Gainesville, 1966. Internship, Parkland Memorial Hos-
pital, 1967. Residency, Mayo Clinic, 1971. Board certified.
HOT SPRINGS
Hardy, Ross Alan, Physical Medicine and Reha-
bilitation. Medical Education, UAMS, 1992. Internship/
Residency, 1996.
JONESBORO
McClurkan, Michael Bruce, Obstetrics/Gynecol-
ogy. Medical Education, UAMS, 1992. Internship/Resi-
dency, University of Mississippi Medical Center, 1993/1996.
LITTLE ROCK
Patrick, Larry L., Anesthesia. Medical Education,
UAMS, 1977. Internship, University Hospital & VA
Hospital, Little Rock, 1978. Residency, UAMS, 1980.
Board certified.
Schrader, Nancy Lynn, Emergency Medicine.
Medical Education, University of Tennessee, Memphis,
1987. Internship/Residency, UAMS, 1988/1990. Board
certified.
RUSSELLVILLE
West, Boyce W., General Practice. Medical Educa-
tion, UAMS, 1970. Internship, St. Vincent Infirmary,
Little Rock.
SMACKOVER
Roper, Richard Kyle, Family Practice. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
AHEC-El Dorado, 1994/1996. Board certified.
RESIDENTS
Chodimella, Ushasree, Internal Medicine/Hema-
tology-Oncology. Medical Education, Andhra Medi-
cal College, Vishakhapatnam, India, 1983. Internship,
458
Andhra Medical College/King George Hospital, India.
Residency, Aultman & Timken Mercy Hospitals, Can-
ton, Ohio. Fellowship, UAMS.
Lamb, Trent Robert, Family Medicine. Medical
Education, UAMS, 1995. Internship/Residency, UAMS,
AHEC-NE.
Schultz, Charles Edward, Internal Medicine/Neu-
rology/Emergency. Medical Education, Medical Col-
lege of Ohio at Toledo, 1992. Internship, Ohio State
University, Columbus, 1993, Residency, Indiana Uni-
versity, 1996, Fellowship, Indiana University.
Tatum, Robert Erwin, Internal Medicine. Medical
Education, University of Mississippi School of Medi-
cine, Jackson, 1990. Internship/Residency, UAMS.
Young, Matthew Stephen, Emergency Medicine.
Medical Education, UAMS, 1996. Residency, UAMS.
STUDENTS
Leigh Anne Bennett
Brian Curtis
Bryan Phillip Tygart
Michael N. Wiggins
Kelli Ruth Wilson
Why should you
JOIN THE
AMS?!
The Arkansas Medical Society is a state-
wide organization that represents ALL PHY-
SICIANS, regardless of specialty, location or
type of practice.
The result is a statewide network united for
the common good of the medical profession.
The management and staff of the Arkansas
Medical Society provide members with the
best information and services available.
If you would like to become a member and/
or would like to find out more about the
Arkansas Medical Society, call:
(501) 224-8967
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Radiological Case
of the Month
Steven R. Nokes, M.D., Editor
Authors
Steven R. Nokes, M.D.
James D. Holloway, M.D.
Thomas H. Hoffman, M.D.
History:
This 65-year-old female presented with tearing chest pain. A chest film was unremarkable. A spiral CT scan of the
chest was performed (figures 1 a-c).
Figures:
Figure 1 (a-c). Axial contrast enhanced spiral CT scans at the level of the left atrium (both the ascending and
descending aorta are seen).
Volume 93, Number 9 - February 1997
459
Motion Artifact Simulating Aortic Dissection
Diagnosis: Motion artifact simulating aortic dissection.
Findings: The three images of the ascending aorta reveal a linear low density line simulating an intimal flap. The
descending aorta is normal. Reconstructed images (Figure 2 a-b) using less than 360° reconstruction are normal.
Figure 2 (a-b): Retrospective 180° reconstructions of two of the slices through the aortic root revealing a normal aorta.
Discussion: Acute aortic dissection is the most common emergency of the aorta. Untreated, the mortality is 25% in
the first 24 hours, 70% during the first two weeks, and 90% after two weeks. Aortography once the mainstay of
diagnosis is invasive and is less sensitive for the detection of dissection than was once thought (only 88% sensitive;
94% specific), and has been supplanted in the last decade by noninvasive techniques.
Spiral CT is probably the most widely used technique for the diagnosis of aortic dissection as it has been shown
to be 1 00% sensitive and specific, is widely available, allows for accurate follow-up and is relatively operator indepen-
dent. An intimal flap is considered diagnostic. Several important diagnostic pit falls may present difficulty in interpre-
tation, however, including penetrating atherosclerotic ulcers, mural thrombi in fusiform aneurysms, periaortic soft
tissue masses, apparent high attenuation of the aortic wall in anemia, and lastly artifacts. A common artifact, pre-
sented in our case, is the result of the improved speed of spiral CT scanners. The one second scan cycle results in a
curvilinear artifact in the root of the aorta that simulates an intimal flap. The artifact is not vendor specific, and has
been described on images obtained with General Electric, Siemens, and Imatron equipment. Our case was per-
formed with an Elscint Twin CT. Aortic motion causes the artifact due to a difference in shape and position of the
aortic root during systole and diastole. The artifact can be eliminated by reconstructing the data using a retrospective
1 80° rather than the routine 360° of information (figure 2 a and b). This requires the operator to save the raw data on
all dissection studies.
Recognition of this artifact is vital to prevent incorrect diagnosis of a Stanford type A dissection (involving the
ascending aorta) as all of these dissections require urgent surgery. Stanford type B (confined to the descending
aorta) are generally treated medically. Surgical treatment is required for patients with treatment failure, progressive
dissection with major branch occlusion or progressive dilatation of the false lumen with compression of the true lumen.
References:
1. Posniak HV, Olsen MC, Demos TC. Aortic motion artifact simulating dissection on CT scans: elimination with reconstructive segmented
images. AJR 1993; 161:557-558.
2. Fisher ER, Stern EJ, Godwin JD, Oho CM, Johnson JA. Acute aortic dissection: typical and atypical imaging features. Radiographics 1994;
14:1263-1271.
3. Sommer T, Fehske W, Holzknecht N, et al. Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal
echocardiography, and MR imaging. Radiology 1996; 199:347-352.
Editor and Author:
Steven R. Nokes, M.D. is associated with Radiology Consultants in Little Rock.
Authors:
James D. Holloway, M.D. is associated with Arkansas Cardiology in Little Rock.
Thomas H. Hoffman, M.D. is associated with Cardiovascular and Thoracic Surgery in Little Rock.
460
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
In Memoriam
Robert B. Benafield, M.D.
Dr. Robert B. Benafield of Conway died Monday, December 9,
1996. He was 64. He is survived by his wife, Helen Speaker Benafield;
a son. Dr. Robert B. Benafield, Jr., of Atlanta, Ga.; two daughters,
Leslie Ford and son-in-law Mike Ford, and Lenlie Freeman and son-
in-law Karl Freeman, all of Conway; a sister, Wanda Harper of Hot
Springs; a brother, J. W. "Buddy" Benafield of Little Rock; four grand-
children, Adam, Rachel and David Bryan Ford and Lauren Freeman,
all of Conway.
Col. Eaton Wesley Bennett, M.D.
Col. Eaton Wesley Bennett, M.D. of Little Rock died Monday,
December 9, 1996. He was 90. He is survived by his wife of 66 years,
Louise Ogden Bennett; two daughters, Margaret Elder Cornett of
Little Rock and Sylvia Ogden Danek of Albuquerque, N.M.; a son,
James Oliver Bennett of Knoxville, Tenn.; a brother, John A. Bennett
of Astor, Fla.; a sister, Blanche Christy of Midland, Texas; 12 grand-
children and 14 great-grandchildren.
Volume 93, Number 9 - February 1997
461
Things To Come
March 6-8
47th Annual Surgical Forum. Sheraton Grande
Hotel, Los Angeles, California. Sponsored by the So-
ciety of Graduate Surgeons. For more information, call
(213) 937-5514.
March 7-9
Management of the HIV-Infected Patient; A Prac-
tical Approach for the Primary Care Practitioner.
Crowne Plaza Manhattan, New York City. Sponsored
by the Center for Bio-Medical Communication, Inc.,
in collaboration with the American Foundabon for AIDS
Research. For more information, call (201) 385-8080.
March 21-25
North American Skull Base Society 8th Annual
Meeting Combined with 2nd International Congress
on the Cerebral Venous System 2nd International
Congress on Meningiomas. The Excelsior Hotel, Little
Rock, Arkansas. For more information, call (301) 654-6802.
March 24-26
NIH Consensus Development Conference: Man-
agement of Hepatitis C. Natcher Conference Center,
National Institutes of Health, Bethesda, Maryland.
Sponsored by the National Institutes of Health. For
more information, call (301) 770-3153.
April 4-5
Clinical Pulmonary Update. Washington Univer-
sity Medical Center, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. Eor more infor-
mation, call 1-800-325-9862.
April 10-12
Refresher Course & Update in General Surgery.
The Ritz-Carlton Hotel, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 11-13
Infectious Disease 97: A Comprehensive Review
for the Practicing Physician. Renaissance Washing-
ton D.C. Hotel - Downtown. Sponsored by the Center
for Bio-Medical Communication, Inc. For more infor-
mation, call (201) 385-8080.
April 17-20
National Kidney Foundation 6th Annual Spring
Clinical Nephrology Meetings Consultative Nephrol-
ogy Program. Wyndham Anatole Hotel, Dallas, Texas.
For more information, call 1-800-622-9010.
April 25-27
1997 Pediatric Update for the Primary Care Phy-
sician. The Westin Canal Place, New Orleans, Louisi-
ana. Co-sponsored by the Alton Ochsner Medical Foun-
dation and Tulane University School of Medicine. For
more information, call (504) 842-3702 or 1-800-778-9353.
May 1-3
Arkansas Medical Society Annual Session - Scal-
ing New Heights. Arlington Hotel, Hot Springs. For
more information, call 1-800-542-1058 or 501-224-8967.
May 8-10
Ambulatory Surgery '97; Sharing Our Experiences
FASA 23rd Annual Meeting. Marriott Copley Place
Hotel, Boston, MA. For more information, call (703)
836-8808.
May 21-24
National Rural Health Association 20th Annual
National Conference: Caring for the country... Partnerships
for Health. Westin Hotel, Seattle, Washington. For more
information, write to NRHA, One West Armour Bou-
levard, Suite 301, Kansas City, Missouri, 64111.
September 5-7
4th Annual Current Topics in Cardiothoracic
Anesthesia. Washington University Medical Center,
St. Louis, Missouri. Sponsored by the Office of Con-
tinuing Medical Education, Washington University
School of Medicine. For more information, call 1-800-
325-9862.
September 18-20
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
October 26-30
1997 State-of-the-Art Conference; Occupational
and Environmental Medicine. Nashville, Tennessee.
Sponsored by the American College of Occupational
and Environmental Medicine. For more information,
call (847) 228-6850, ext. 152.
462
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
.ife. x' K
Arkansas Medical Society
'll i\ii
' A
1997 Annual Session
May 1-3, 1997
iMliili ■ '1
',1
Scaling New Heights
fiiijl'r j
Pjiffiiili ' Tim
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Arlington Hotel
Hot Springs, Arkansas
Watch your mail for registration materials.
The Arkansas Medical Society
Seeks Nominations
for the 1997 Shuffield Award
The Arkansas Medical Society is seeking nomi-
nations for the 1997 Shuffield Award which will
be presented at the annual meeting in Hot Springs,
May 1 -3, 1997.
The Shuffield Award is given each year to rec-
ognize lay persons in Arkansas who have done out-
standing community work in the health care field.
The individual might be a newspaper reporter, tele-
vision personality, government official, teacher or
individual promoting a community or other health
related program. The person cannot be a physician
or member of a physician’s immediate family.
The nominations may come from the county
medical societies or any medical society or alliance
member. The deadline for receipt of nominations
is Friday, February 28, 1997. Past nominees may
be renominated.
If you know someone worthy of this honor,
please contact the AMS office at 501-224-8967 or
1-800-542-1058 for a nomination form.
Volume 93, Number 9 - February 1997
463
Keeping Up
March 1, 1997
Southwest Arkansas Physician Update. Time: 8:30 a.m. - 3:30
p.m. Location: Lile Hall, Quachita Baptist University, Arkadelphia.
Accrediting organization sponsoring program: UAMS College of
Medicine. Hours of Category 1 credit offered: To be determined.
Fee: To be determined. For more information, call (501) 661-7962.
March 1, 1997
Diabetes Update. Time: 8:00 a.m. - 4:00 p.m. Location: Little Rock,
Hilton Inn. Program presenters: UAMS Division of Endocrinology/
Arkansas Diabetes Program Course Director: Dr. Vivian Fonseca.
Accrediting organization sponsoring program: UAMS College of
Medicine. Hours of Category 1 credit offered: 5.5. Fee: Before Feb-
ruary 1, 1997, Physicians - $75 and others - $50; after February 1,
1997, Physicians - $100 and others - $60. For more information,
call (501) 661-7962.
March 4, 1997
Obesity: Common Symptom of Diverse Gene-Based Metabolic
Dysregulations. Time: 8:00 a.m. - 4:30 p.m. Location: Little Rock,
Excelsior Hotel. Program presenters: UAMS and Biochemistry and
Molecular Biology. Accrediting organization sponsoring program:
UAMS College of Medicine. Hours of Category 1 credit offered:
5.5. Fee: To be determined. For more information, call (501) 661-7962.
March 14-15, 1997
Neurology for the Primary Care Physician. Time: 8:00 a.m. -
4:00 p.m. Location: Little Rock, Hilton Inn Select. Program pre-
senters: UAMS Department of Neurology. Accrediting organiza-
tion sponsoring program: UAMS College of Medicine. Hours of
Category 1 credit offered: To be determined. Fee: $150 for Physi-
cians. For more information, call (501) 661-7962.
March 1, 1997
Diabetes Update. Time: 8:00 a.m. - 4:00 p.m. Location: Little Rock,
Hilton Inn. Program presenters: UAMS Division of Endocrinology/
Arkansas Diabetes Program Course Director: Dr. Vivian Fonseca.
Accrediting organization sponsoring program: UAMS College of
Medicine. Hours of Category 1 credit offered: 5.5. Fee: Before Feb.
1, 1997, Physicians-$75 and others-$50; after Feb. 1, 1997, Physi-
cians-$ 1 00 and others-$60. For more information, call (50 1 ) 66 1 -7962.
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category 1 of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon, Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Breast Conference, 3rd Thursday, 7:00 a.m., J.A. Gilbreath Conference Center, Room #20
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Disorders Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
464
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The University of Arkansas College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor the
following continuing medical education activities for physicians. The Office of Continuing Medical Education designates that these activities
meet the criteria for credit hours in category 1 toward the AMA Physician's Recognition Award. Each physician should claim only those
hours of credit that he/she actually spent in the educational activity.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Fetal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
Volume 93, Number 9 - February 1997
465
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology/ Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
Primary Care Conferences, 1st & 3rd Mondays, 12:00, every Tuesday 7:30 a.m., Washington Regional Medical Center
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital CME Conference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
466
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetricsl Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkajisas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 9 - February 1997
467
^ Advertisers Index
Advertising Agencies in italics
AMS Benefits inside back
Arkansas Children's Hospital back cover
Autoflex Leasing inside front
Care Network 444
The Alan Rothman Company, Inc.
Consumer Quote USA 435
Freemyer Collection System 451
Medical Practice Consultants, Inc 442
Riverside Motors, Inc 448
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory 441
Strategic Marketing
State Volunteer Mutual Insurance Company 430
The Maryland Group
Southwest Capital Management 440
Marion Kahn Communications, Inc.
U.S. Air Force 429
BJK&E Specialized Advertising
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
journal. Material appearing in The Journal of the Arkansas
Medical Society is protected by copyright. Manuscripts
may not be reproduced without the written permission of
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The Journal of the Arkansas Medical Society reserves the
right to edit any material submitted. The publishers accept
no responsibility for opinions expressed by the contributors.
All manuscripts should be submitted to Tina G. Wade,
Managing Editor, Arkansas Medical Society, P.O. Box
55088, Little Rock, Arkansas 72215-5088. A transmittal
letter should accompany the article and should identify
one author as the correspondent and include his/her
address and telephone number.
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Author information should include titles, degrees,
and any hospital or university appointments of the
author(s). All scientific manuscripts must include an
abstract of not more than 100 words. The abstract is a
factual summary of the work and precedes the article.
Manuscripts should be typewritten, double-spaced, and
have generous margins. Subheads are strongly encour-
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Pages should be numbered. Manuscripts are not re-
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REFERENCES
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THE Journal
OF THE Arkansas
MEDICAL SOCIETY
Volume 93 Number 10
HEALTH SCONCES LIBRARY —
UNIVERSITY OF MARYLAND. AT
BALTIMORE
~ titled Clinicopathological Images - page 489 - Get Acquainted with Dr. Samuel E.
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ro I
a< i-j -v-i
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Landrum -page497-AreHred physician looks backat his decision to be a country doctor - page
472 - AMS Annual Session Schedule - page 498 - and much more inside...
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE PRESIDENT
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
Obstetrics! Gynecology
Internal Medicine
Surgery
Family Practice
UAMS
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
Volume 93 Number 10 March 1997
CONTENTS
FEATURES
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
472 Through barbed wire and over a fence, to grandmother's
house we go - The challenges and rewards of being a rural physician
Editorial
Ben N. Saltzman, M.D.
474 Medicine in the News
Health Care Access Foundation Update
UAMS Receives $25.5 Million Grant for Geriatrics
Disciplinary Action Bulletin - Arkansas State Board of Nursing
479 New Member Profile
Istvan Molnar, M.D.
481 Progress Report: Evaluation and Treatment of Ascending and
Aortic Arch Aneurysm/Dissection
Scientific Article
Frederick A. Meadors, M.D.
485 Needed - Documentation in Quotation Marks
Loss Prevention
/. Kelley Avery, M.D.
489 Clinicopathological Images • * *
497 Getting Acquainted with Samuel E. Landrum, M.D., Journal
Editorial Board Member
NEWSECTION
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information: Contact Tina G. Wade, The
Journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
Press, Inc., Fulton, Missouri 65251 . Periodicals postage
is paid at Little Rock, Arkansas, and at additional
mailing offices.
Articles and advertisements published in The Journal
are for the interest of its readers and do not represent
the official position or endorsement of The Journal or the
Arkansas Medical Society. The Journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1997 by the Arkansas Medical Society.
DEPARTMENTS
478 AMS Newsmakers
490 Cardiology Commentary & Update
495 State Health Watch
499 Radiological Case of the Month
502 In Memoriam/Resolutions
503 Things to Come
504 Keeping Up
Cover artwork, titled "Eye on the Imagination, " is by El Dorado artist Julie Waschka. Artwork
made available by the Arkansas Artists Registry, a part of the Arkansas Arts Council, an agency
of the Department of Arkansas Heritage.
Editorial
Through barbed wire and over a fence, to
grandmother's house we go - The challenges and
rewards of being a rural physician
Ben N. Saltzman, M.D.*
As I look back upon my early experiences in the
practice of general medicine in Mountain Home and
Baxter County, I am reminded of the decisions I made
to opt for a career as a country doctor as opposed to
the hopes and wishes of my parents.
I spent six years in the Panama Canal Zone as an
intern and resident at Gorgas Hospital. I thought seri-
ously of making Canal Zone Medicine a career.
During my stint as an intern and resident, I be-
came acquainted with Dr. Rector Hooper. His home
was Rosey, Arkansas, quite close to Batesville. He was
one year ahead of me and acted as my mentor at the
hospital.
Dr. Hooper resigned his commission and returned
to Arkansas immediately after the cessation of hostili-
ties. He joined a medical group in Batesville, and ac-
quired a Dr. Elisha Gray as a patient from Mountain Home.
Dr. Gray was aging rapidly and wanted to find a
physician to replace him and to take over his practice.
Dr. Hooper suggested me and called me long distance.
He told me about the progress being made by the com-
munity of Mountain Home with the completion of the
Norfork Dam and the planning for the construction of
Bull Shoals Dam. The population at the time was only
1200, but increasing rapidly. The soldiers were com-
ing home and babies were being born. Retirees were
also moving in. He could promise me a very active
practice. My wife, Betty, and I agreed to give it a try.
We felt that if we became dissatisfied, we could al-
ways try something else. Our daughter Sue Ann was
one year old and a good traveler.
Dr. Hooper drove me from Batesville to Mountain
Home over one of the worst roads I have ever trav-
eled. It was nothing but rock, dirt, and potholes. The
only pavement was the street around the new Court-
house Building. Office space, transportation, office
help, and a home were not readily available. I had to
overcome these obstacles while my wife and daughter
* Dr. Saltzman is a retired family practitioner from Mountain
Home. He is a member of the AMS Fifty Year Club and
editorial board for The Journal of the Arkansas Medical Society.
lived with the Hoopers for about 6 months. Despite
all of this, I wanted to stay. It was a challenge, and
Dr. Gray was marvelous. He had written letters to his
patients and they were waiting for me. I really felt wanted.
I became somewhat of an obstetrician. I utilized a
collapsible delivery table that Dr. Gray had utilized
over the years. He gave it to me, and it did the job.
My deliveries were all done in the homes of the people
all over the county and into the adjoining counties.
The difficulty with having to deliver so many babies is
that I couldn't see office patients. As one can imagine,
I was busy day and night. Yet the people of Baxter
County understood and made allowances.
My parents were not particularly happy with my
decision to go into rural practice. They had hoped that
coming out of the military I would settle into a big city
practice, namely in Jacksonville, Florida, near their
home. They couldn't understand why I would want
to be a country doctor. I tried to tell them in letters
about experiences with my patients and how much I
learned from them and from the few retired doctors in
the area. (The retired physicians were happy to share
what they knew with me.)
One day two ladies came to see me with a plea I
couldn't resist. Their grandmother had been bedfast
for about a month. She had been in a coma for about
three weeks and had been hospitalized for two weeks
before being returned home, unimproved. Finally, the
ladies were told that there was little hope that their
grandmother would survive. They asked me if I would
come out to see the little lady and perhaps think of
something that might help.
I did not think that I would find something useful
with her past history, but agreed to try. The home
was located about five miles outside of Mountain home.
I had to open two barbed wire gates and finally step
over a stile to get to the house. It just so happened
that my Dad had come to Mountain Home to see how
I was getting along. I invited him to come with me
and hoped that he would understand me better if he
saw some of the obstacles as well as the satisfaction
472
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
that could be derived from this type of practice.
I carried a liter of D5W, a stand, some sterile I.V.
needles and plastic tubing to the house. I fortunately
found a vein that could be utilized several times. I
showed the ladies how to shut off the fluid, remove
the needle and hold pressure over the vein after the
removal of the needle. I informed them that I would
be back daily for one week with the same treatment. I
complimented them on the cleanliness of the house
and their care of the patient and urged them not to
give up too soon.
My dad and I made our trips daily hoping for im-
provement, but seeing little. On return to the clinic
each day, my Dad asked me if I wouldn't have had a
better life if I had gone into practice in Florida. 1 re-
sponded that this was a challenge and hoped that I
could meet many such challenges in my life.
On Sunday, the last day of this particular week,
we arrived at the house and were greeted at the door
by one of the granddaughters. I could hear some con-
versation in the bedroom. We walked into the bed-
room and saw granny sitting in a chair next to the
bed. She greeted me in a friendly manner. I was re-
lieved and happy to see the faces of the granddaughters.
On the way home, my father said to me for the
first time in my life, "Son, I'm proud of you."
I later learned that granny lived for several more
useful years.
How CAN YOU GET YOUR
MESSAGE TO A FEW HUNDRED
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product or offering a new service?
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answer... exhibit at their annual meeting.
The AMS works to draw every physician
who attends to the exhibit area. Several of
the breakfasts, lunches and afternoon
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There is usually almost 300 physicians.
What better way to reach that many
physicians in just a few hours.
Don’t let this opportunity pass. The cost is
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send or FAX you registration materials.
Sponsorships are also available. Call today -
space is limited.
May 1-3, 1997
Arlington Hotel
Hot Springs, Arkansas
Arkansas Medical Society
1997 Annual Convention
May 1-3, 1997
Scaling
New
Heights
Arlington Hotel
Hot Springs, Arkansas
Volume 93, Number 10 - March 1997
473
Medicine in the News
Health Care Access Foundation
As of February 1, 1997, the Arkansas Health Care
Access Foundation has provided free medical service
to 12,210 medically indigent persons, received 23,061
applications and enrolled 44,957 persons. This program
has 1,757 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
UAMS Receives $25.5 Million Grant for
Geriatrics
Thanks to a $25.5 million grant from the Donald
W. Reynolds Foundation, the University of Arkansas
for Medical Sciences will establish the new Donald W.
Reynolds Department of Geriatrics and construct the
Donald W. Reynolds Geriatrics Center.
Fred W. Smith, Chairman of the Donald W.
Reynolds Foundation, explained that $10.5 million will
be used to establish the Donald W. Reynolds Depart-
ment of Geriatrics in the College of Medicine and $15
million will build and equip the Donald W. Reynolds
Geriatrics Center. He said, "As the second geriatrics
department established in the United States, the new
Donald W. Reynolds Department of Geriatrics is being
funded over a five-year period through the Donald W.
Reynolds Foundation's initiative on aging and quality
of life program."
"This is the largest grant from a single-funding
source ever given to a public institution of higher edu-
cation in Arkansas," said UAMS Chancellor Harry P.
Ward, M.D. "Arkansas has both the people and the
programs to support the new Donald W. Reynolds
Department of Geriatrics. One of the supporters is
Senator David Pryor whose national leadership in
health policy has brought public attention and con-
cern to older Americans' needs. Statewide, our many
physicians and health care professionals working in
the six Area Health Education Centers (AHEC) will
benefit and contribute to the Donald W. Reynolds
Department of Geriatrics."
Ward added, "In the past decade, UAMS has in-
creasingly emphasized the area of aging. Through our
affiliation with the John L. McClellan Veterans Affairs
Medical Center, UAMS established one of the first
Geriatric Research Education and Clinical Centers
(GRECC) in the nation with funds provided by the
Veterans Administration. Our emphasis on the study
of aging is also a major educational concern of the
UAMS Colleges of Nursing, Pharmacy, and Health Re-
lated Professions."
Artist's rendering of the Donald W. Reynolds Geriatric Center by
Brooks Jackson Architects Inc.
The new chairman of the Donald W. Reynolds
Department of Geriatrics - David A. Lipschitz, M.D.,
Ph.D. - said, "With this generous grant, we will train
geriatricians to meet the overall physical and emotional
health needs of older people. We will promote func-
tional independence among the elderly, and we will
show caregivers - many of them daughters and sons
of aging parents - how to cope. Our health services
research will help identify and solve quality-of-life prob-
lems for the elderly who are projected to reach 20 per-
cent of the U.S. population by 2020. In addition, we
will address national health issues related to serving
the "baby boom" generation in the 21^'* century."
Mrs. Jo Ellen Ford, member of the UAMS Founda-
tion Board and Chairman of the Center on Aging Com-
munity Advisory Committee Board, said that UAMS
now has the opportunity to better determine how best
to care for older citizens. She said, "Just as children
are not merely small adults, we developed our current
specialized Department of Pediatrics that is appreci-
ated by all Arkansans. With the same commitment,
UAMS will show that older adults have catastrophic
diseases with complicated medical problems, which
require different approaches to treatment. The new
Donald W. Reynolds Department of Geriatrics will bring
together health care professionals in one place where
complex equipment can be acquired and specialized
skills can be pooled and developed."
During the grant presentation ceremony, I. Dodd
Wilson, M.D., Dean of the College of Medicine and
UAMS Executive Vice Chancellor, said, "With the high
percentage of older persons living in Arkansas, the
new Donald W. Reynolds Department of Geriatrics fits
the profile of our population. We are fortunate to have
the support of Robert Butler, M.D., who now is serv-
474
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Tomorrows Healthcare Professionals...
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FINALLY, a health insurance plan designed to meet the needs of Arkansas' physicians. The ARKANSAS
MEDICAL SOCIETY HEALTH BENEFIT PROGRAM... offering a variety of benefit options including a choice
between basic indemnity and managed care. For information call (501) 224-8967 or 1-800-542-1058.
Arkansas Medical Society
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P.O. Box 55088, Little Rock, Arkansas 72215-5088 • (501)224-8967 * WATS 1-800-542-1058 • FAX (501) 224-6489
Ask about our other services includine Professional Overhead. Disability & Life Insurance
ing as a consultant to the Donald W. Reynolds Foun-
dation. Under Butler's direction, the only other geriat-
rics department in the country was established at the
Mount Sinai School of Medicine in New York. We look
forward to working with Steven L. Anderson, Chair-
man of the Donald W. Reynolds Foundation's Com-
mittee on Aging and Quality of Life, as we establish
milestones for the next five years."
The newly adopted mission of the Donald W.
Reynolds Foundation is to present grants to qualified
charitable organizations in Arkansas, Nevada and
Oklahoma. The Foundation's Capital Grants Program
annually reviews organizations that demonstrate sus-
tainable programs, exhibit entrepreneurial spirit, and
assist those served to be healthy, self-sufficient and
productive members of their communities. The
Reynolds Foundation - with offices in Tulsa, Oklahoma
and Las Vegas, Nevada - has assets exceeding $1 bil-
lion. According to the Foundation Center's ranking,
the Donald W. Reynolds Foundation is among the
nation's 30 largest.
Donald W. Reynolds was the founder and princi-
pal owner of Donrey Media Group which, at the time
of his death in 1993, included 52 daily newspapers, 10
outdoor advertising companies, five cable television
companies and one television station.
The Need for Geriatricians
Over the next 20 years, the percentage of the U.S.
population that is over the age of 65 will explode. To-
day, only l/8th of our nation is considered elderly; in
20 years, more than l/5th will be over the age of 65.
In Arkansas, there are already many communities
with more than l/5th of the residents over age 65. This
population mix reflects today what our entire nation
will look like by the year 2020. A large fraction of the
elderly in this state live in rural areas. Many are disad-
vantaged and have little or no access to basic health
care services — not to mention specialized geriatric care.
Arkansas spends more Medicare dollars per capita than
any other state in the country. Despite this expendi-
ture, older Arkansans rank near the bottom in terms
of overall health in the nation.
But sadly, as our aging parents enter the autumn
of their lives today in the midst of a culture that prizes
youth, they often find that modern medicine can pro-
long their suffering rather than relieve it. The chal-
lenge facing the field of geriatrics today is to help adults
enjoy a longer lifespan with good health and to teach
the elderly how to live with the natural aging process
with grace and dignity. To achieve this, our health
care system will need more geriatricians. At the root
of this problem is the question — who is educating
physicians and other health care professionals about
the special health problems of older persons?
At present, there is only one medical school in the
nation with a department of geriatrics. It's located in
New York City at Mt. Sinai Hospital. With the public
announcement at UAMS in Little Rock on February 4,
1997, there is now a second one: the Donald W.
Reynolds Department of Geriatrics within the UAMS
College of Medicine.
Twenty-year Record of Geriatrics at UAMS
Geriatric initiatives at UAMS began about 20 years
ago when Eugene Towbin, M.D., then Chief of the
Veteran's Administration Hospital located on Roosevelt
Road, had the foresight to persuade the Veterans Ad-
ministration to develop a handful of centers of excel-
lence in geriatrics across the nation.
In 1975, the VA Hospital in Little Rock was one of
the first VA facilities in the nation to be awarded a
Geriatric Research Education and Clinical Center
(GREGG). It remains in operation today within the
John L. McClellan Memorial VA Medical Center adja-
cent to the UAMS campus and affiliated with the Col-
lege of Medicine.
This 20-year commitment to geriatrics and geron-
tology has produced an array of nationally-recognized
programs in geriatrics education, health, and research.
This well established GREGG program is the founda-
tion upon which the Donald W. Reynolds Department
of Geriatrics will be built.
The Vision of the Donald W. Reynolds Department of
Geriatrics
The fundamental mission of the department is to
present training in geriatrics to all medical students
and to offer special training for those physicians who
aspire to become geriatric specialists.
A major focus of the work conducted by the de-
partment in its new facility will be to promote func-
tioned independence in older persons and to develop
solutions that will prepare the health care system for
the aging of the baby boom generation.
Clinical programs will target patients who are de-
pendent as a result of cognitive impairment or because
of physical problems such as stroke, arthritis, or frailty.
The department will also serve healthy older per-
sons and assure that they remain functionally inde-
pendent. Healthy 70-year-olds have many good years
of life ahead of them. Through education, exercise, a
prudent diet, stress management, and careful screen-
ing for age dependent illnesses, UAMS geriatricians
will improve the chances of an older person remain-
ing independent, living in their own home, and en-
joying an excellent quality of life. Although medical
advances based on current research may make it pos-
sible for more people to live longer, the department
will work to assure that the life one has will be of the
476 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
highest quality. The ultimate goal is not necessarily to
prolong life; rather, to optimize it.
The department will study the role of nutrition
and exercise and apply this new knowledge to its pa-
tients — particularly strength training for improving
mobility, minimizing the risk of falling, and improv-
ing the overall health of older persons. Information pro-
vided by UAMS Department of University Relations.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board office should be contacted. There-
fore, the Board routinely suggest this list be shared
with the appropriate supervisory personnel and re-
cruiters in your agency.
At the completion of the disciplinary period, the
nurse applies for reinstatement, which is contingent
upon meeting the conditions set forth by the Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY: Tanuarv 8. 1997
^Deborah Kay Barnhart Gustke, RN 42406, (Cabot)
Probation - 6 months, $500 - Civil Penalty
*W. Belle Jackson Pinegar, RN 30547 (Cabot) Suspen-
sion - 6 months, $500 - Civil Penalty
*Steven Michael Carter, RN 32862 (SUdell, LA) REVOKED
*Sherri J. Carter, RN 32861 (Slidell, LA) REVOKED
*Carla Louise Jones, RN 51673 (Senatobia, MS) Con-
sent Agreement, Probation - 3 years, $500 - Civil Penalty
*Sharon Denise Brooks Anthony, LPN 31829 (Moun-
tain Home) Consent Agreement, Probation - 2 years,
$500 - Civil Penalty
*Carla Lynn Bridges Mille, LPN 28011 (Little Rock)
Consent Agreement, Probation-2 years, $500 - Civil Penalty
*Kathy Ann Jones Peer, LPN 21264 (Little Rock) Con-
sent Agreement, Probation-1 year, $500 - Civil Penalty
*Lynetta Walker Buckley, LPN 18456 (Little Rock) Con-
sent Agreement, Probation-1 year, $500 - Civil Penalty
*Manda Beth Sample Rhines, LPN 30252 (Batesville)
Consent Agreement, Probation-2 years, $500 - Civil Penalty
LETTER OF REPRIMAND;
’^Sheila Karen Kelly Beck, LPN 14045 (Franklin, AR)
11/25/96
VOLUNTARY SURRENDER:
*John Edward Cigrang, RN 34367 (Mabelvale) 12/16/96
^Deborah Dickinson, LPN 18506 (Donaldson) 11/21/96
■^Deborah Lea Powell, RN 44419 (Little Rock) 12/20/96
^Michael Vincent Sheppard, LPN 24562 (Newport) 11/17/96
ALERT: If you have employed the following nurses or
have any knowledge of their whereabouts, please no-
tify the Board of Nursing at (501) 686-2700.
*Julie M. Duvall, RN 49140
*Debra Bussiere, RN 51249
♦Carol L. Earls, LPN 26589
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Volume 93, Number 10 - March 1997
477
AMS Newsmakers
Dr. Mary Louise Corbitt, a neurologist in
Sherwood, recently completed Medical Acupuncture
for Physicians sponsored by Continuing Medical Edu-
cation, UCLA School of Medicine. She received 200
Hours in Category 1.
Dr. Ralph Joseph, a physician of internal medi-
cine in Walnut Ridge, has been selected to receive the
Sam Walton Business Leader Award sponsored by the
Wal-Mart Foundation. The Walnut Ridge Area Cham-
ber of Commerce selected Dr. Joseph to receive the
award.
Dr. Robert McCarron, a Conway orthopedic sur-
geon, has been included in Who's Who in Medicine
and Healthcare for significant achievement in the medi-
cal field. Published by Marquis Who's Who, the book
is a guide to 20,000 of today's leaders in the diverse
fields of medicine and healthcare.
Dr. James Suen of Little Rock recently received a
medallion of honor as the first recipient of the James
Y. Suen, M.D., Endowed Chair in Otolaryngology -
Head and Neck Surgery at UAMS. The chair was es-
tablished with more than $1.2 million raised from
friends and former patients of Suen's.
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Dr. Suzanne Wong Yee, a Little Rock otolaryn-
gologist and plastic surgeon, has been selected by
KATV Channel 7 as its new medical correspondent to
appear on "Daybreak" every Wednesday morning to
answer health questions by viewers.
The Physician's Recognition Award is awarded
each month to physicians who have completed accept-
able programs of continuing education. Recipients for
November 1996 are: Michael Alan Chavin of Stuttgart;
Benjamin Harrison Hall of Lincoln; Edward Parnell
Hammons of Brinkley; Don Gene Howard of Fordyce;
David E. Rowe of Pine Bluff and Eugene F. Still of Fort
Smith.
Send your accomplishments and photo for
consideration in AMS Newsmakers to:
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
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478
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
New M
Profile
Istvan Molnar, M.D.
PROFESSIONAL INFORMATION
Specialty: Internal Medicine - Oncology
Years in Practice: First year
Office: Newport
Medical School: Semmelweis Medical School in Budapest, Hungary, 1991
Internship! Residency: Meridia Huron Hospital in Cleveland, Ohio, 1993
Volunteer work: American Cancer Society
PERSONAL INFORMATION
Date/Place of Birth: January 15, 1967 in Jaszbereny, Hungary
Spouse: Andrea Kiss, M.D., resident physician
Children: Daughters, Fruzsina and Luca, five and eight years old
Hobbies: Tennis, reading and classical music
THOUGHTS & OTHER INFORMATION
If I had a different job, I'd be: A businessman
Person I most identify with: John Lennon
Favorite junk food: Hamburgers
Behind my back, they say: I am moody
Most valued material possession: My car
People who knew me in medical school, thought I was: Smart
The turning point of my life was when: I got married
Favorite vacation spot: Black Sea in Bulgaria
One goal I haven't achieved, yet: Travel around the world
One goal I am proud to have reached: Private practice in medicine
When I was a child, I wanted to grow up to be: A musician
First job: Nurse's aide
One word to sum me up: Relaxed
My philosophy on life: Enjoy life every day to the fullest
If you would like to appear in New Member
Profile or Member Profile, contaet Tina Wade
at AMS at (50 1 ) 224-8967 or 1 -800-542- 1058.
Volume 93, Number 10 - March 1997
479
1997 Arkansas Mescal
Society Annual Convention
Seating New Heights
6 Reasons Why you should attend
May 1-3, 1997
1 . The Arkansas Medical Society’s Annual
Convention offers educational programs on a
wide range of topics relating to the field of
medicine. CME hours are available.
2. The AMS looks to provide our
members with cutting edge information
about the products and services available to
support their practice. The convention
features exhibits from over 70 companies.
3. Participation in the AMS House of
Delegates meeting gives county medical
societies a voice in the policies of the state
association.
4. The young physicians seminar “Getting
Started in Medical Practice” is designed for
residents and other physicians by addressing
topics that physicians may face as they begin
a medical practice.
5. Social events for AMS members and
their guests include the Dr. Harold “Bud”
Purdy Memorial Golf Tournament,
receptions with a variety of entertainment.
6. A great opportunity for old and new
friends to relax and exchange ideas.
Watch your mail for registration materials!!
Scientific Article
Progress Report: Evaluation and Treatment of
Ascending and Aortic Arch Aneurysm/Dissection
Frederick A. Meadors, M.D.*
Introduction
Numerous clarifications and improvements have
been made in the understanding of disease concepts
involving aortic aneurysm and dissection, procedures
utilized to replace the involved segment(s), and brain
protection during the conduct of ascending-arch aor-
tic operations. A reasonably clear picture now exists
regarding who the surgical candidates should be. Stan-
dardization of contemporary operative techniques of-
fer patients excellent success rates following operations
once thought to be very high risk.
Concepts
Recognition of potentially dangerous pathologic
lesions involving the ascending aorta and/or transverse
aortic arch is the essential first step in understanding
whether the affected patient deserves further evalua-
tion or simple observation. The normal diameter of
the ascending aorta is 3.5 cm. and is the largest seg-
ment of the normal aorta anywhere In the body.’ The
aortic arch diameter gradually tapers, and the descend-
ing thoracic aorta's normal diameter is approximately
2.2 cm. Aneurysms of the ascending aorta and arch
measuring 5.0 cm. are considered low risk lesions,
while 6.0 cm. enlargements are "high risk" for rup-
ture or acute dissection. Mortality with ascending-arch
rupture is greater than 90% within minutes to hours
of occurrence. Mortality from proximal aortic dissec-
tion is 90% within two weeks if left untreated surgically.^
Asymptomatic 5.0 cm. ascending-arch aneurysms
are observed with serial surveillance CT scans or MRI
scans if no other indication for a cardiac surgical pro-
cedure exists. Recommendations for incidentally dis-
covered aneurysms of the ascending aorta greater than
5.0 cm. in patients undergoing coronary artery bypass
grafting or valve replacement are for graft replacement
to prevent subsequent enlargement, rupture, and dis-
section.
On their own merit, aneurysmal enlargements of
the ascending-arch measuring greater than or equal to
* Frederick A. Meadors, M.D., is affiliated with Watkins, Bauer
and Meadors, P.A., Cardiovascular and Thoracic Surgery in
Little Rock.
5.5 cm. should be considered for elective graft replace-
ment because elective operations carry less than 10%
mortality rates and mortality for emergency procedures
is usually in excess of 20%.-’
Proximal Aortic Dissection
Acute proximal (ascending) aortic dissection is a
deadly process. Diagnosis is usually made by CT scan.
MRI, trans-esophageal echocardiography, and aortog-
raphy are also valuable, depending on availability and
the clinician's preference. Once the diagnosis of acute
proximal aortic dissection is made, the consensus of
most experts is to proceed directly to the operating
room without attempting cardiac catheterization be-
cause of the risk of delaying definitive repair and tech-
nical difficulty encountered by the cardiologist engag-
ing the coronary ostia in the presence of an ascending
aortic intimal flap.
Repair of proximal dissection is accomplished via
median sternotomy using profound hypothermic cir-
culatory arrest and intraoperative EEG monitoring.
Blood flow is redirected into the true lumen fol-
lowing obliteration of the false lumen by suturing a
dacron graft to the aortic arch beyond the intimal tear.
The presence of transverse arch intimal tears occurs in
less than 10% of cases and should be repaired by di-
rect suture techniques or completely replaced by arch
grafting.^ Restoring blood flow in the true lumen pre-
vents malperfusion of the brachiocephalic arteries,
spinal cord, viscera, and extremities.
Acute aortic dissection may cause stroke or paraple-
gia from malperfusion of the brain or spinal cord cir-
culation. Patients having sustained acute cerebro-
vascular accidents from dissection malperfusion are
in general not operated upon because of prohibitive
neurologic risk. Paraplegia from acute dissection is
usually permanent and not reversible with proximal
aortic reconstruction; however, since younger victims
may have productive lives with paraparesis/paraplegia,
operation is offered to this group to prevent rupture,
cardiac tamponade, aortic valve commissure
dislodgement or coronary artery ostial damage.
Patients with the dissection process extending into
Volume 93, Number 10 - March 1997
481
the arch and distal aorta need lifelong follow-up with
serial surveillance CT scans of the chest and abdomen
to detect subsequent aneurysmal degeneration.
Crawford, et al, determined that late aneurysmal
degeneration and rupture is a significant cause of late
morbidity and mortality. Long-term control of hyper-
tension is of extreme importance in decreasing the in-
cidence of subsequent distal aneurysm formation in
this group.
Aortic Valve Preservation
There are inherent benefits in preserving the na-
tive aortic valve whenever possible during ascending
aortic operations. Even in the setting of significant
aortic valve insufficiency caused by proximal aortic
dissection, it is possible to preserve the valve with
current techniques, and the results have been durable.
Detailed knowledge of the sino-tubular junction,
anatomy of the ascending aorta, and aortic annulus
facilitates proper application of valve-sparing procedures.
Aortic valve preservation in patients with Marfan
syndrome undergoing aortic root replacement has
gained some international attention. At this time, these
procedures are regarded as experimental, and the
long-term durability remains unknown.
Brain Protection
The technical feasibility of suturing grafts in the
aortic arch was simplified by widespread use of
Cooley's open distal anastomosis under direct vision
utilizing profound hypothermic circulatory arrest
(PHCA). The purpose of systemic cooling using car-
diopulmonary bypass is to reduce brain oxygen con-
sumption as much as possible so that permanent neu-
rologic injury will not occur during PHCA. Intraop-
erative EEC monitoring to guide the depth of cooling
on CPB allows the determination of electro-cerebral
silence. Systemic rewarming following completion of
the arch graft slowly restores a normal EEC tracing as
normothermia is re-established.
Experimentally, the brain temperature must be less
than 22 degrees Celsius to have no electrical activity
and, therefore, minimal metabolic requirements. No
peripheral temperature measurement correlates with
a flat-line EEC tracing; therefore, the continued use of
intraoperative EEC monitoring is justified.^
The safe time period for PHCA has long been de-
bated. In the most extensive series of hypothermic cir-
culatory arrest operations done on the ascending-arch
performed by one surgeon, Crawford demonstrated a
significant increase in the stroke rate at 40 minutes
and death rate at 60 minutes of ischemic time.^ With
short circulatory arrest intervals (less than 20 minutes),
the stroke rate was less than 1%. Proximal arch (or
hemiarch) replacements are usually accomplished
within these time constraints.
482
Total aortic arch replacement (with reattachment
of the brachiocephalic vessels) frequently entails greater
than 35-40 minutes of circulatory arrest time, and ad-
ditional brain protection is felt to be needed by most
authorities performing these procedures to prevent
stroke and death.
Retrograde cerebral perfusion (RCP) through the
superior vena cave (SVC) is a Japanese originated tech-
nique where cold oxygenated pump blood is perfused
backwards through the SVC (hopefully to the brain)
with the rest of the body at circulatory arrest.* Blood
can be seen emanating from the open arch brachio-
cephalic arterial origins during arch replacement and
is thought to be beneficial to the brain for two rea-
sons. Pirst, it removes embolic debris from the carotid
and vertebral arterial circulation by flushing it into the
open operative field. Secondly, the retrograde cere-
bral blood flow nourishes the brain whose metabolic
requirements are not zero.
Clinical series employing RCP have determined it
to be a safe technique. Whether or not RCP is effica-
cious is not yet firmly proven. Animal studies have
demonstrated an inhomogeneous distribution of blood
flow to the brain using RCP.
Antegrade cerebral perfusion during PHCA for
total arch replacement was tried and abandoned 30
years ago in Houston because of a high neurologic
complication rate. This technique has been resurrected
with improved results and accepted because of new
and improved balloon-tipped catheters that can be
passed into the brachiocephalic origins in an atraumatic
manner from inside the open aortic arch. This lessens
the risk of distal embolization to the brain previously
associated with external cannulation of the brachio-
cephalic vessels.
Prosthetic Grafts
Dacron prosthetic grafts have been the standard
conduit for ascending-arch replacement. Newer, com-
mercially available collagen impregnated grafts
(Meadox: Hemashield) have obviated the need for
preclotting with blood or soaking the older dacron
grafts with albumin and baking in the autoclave to
seal interstices and decrease bleeding. Dilation of
Hemashield grafts was initially a concern but does not
appear to be a significant clinical problem. Superior
handling characteristics and ready availability make it
our current graft material of choice.
Composite valve-graft conduits are used for re-
placement of the aortic valve, sinus of Valsalva seg-
ment of the ascending aorta, and varying lengths of
the tubular segment of the ascending aorta. These
procedures are more radical than isolated aortic valve
repair/replacement plus or minus graft replacement of
the supra-coronary ascending aorta because of the
necessity for coronary arterial ostial reattachment. The
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
two commonly employed techniques to accomplish
coronary reattachment are the Bentall procedure (di-
rect aortic wall button reattachment of the right and
left coronary ostia) and modification of the Cabrol pro-
cedure using an 8 or 10 mm. dacron bypass graft sewn
to the aortic wall surrounding the right and left main
coronary ostia and the ascending graft.
The decision to replace the sinus segment and use
a composite valve-graft prosthesis is of extreme im-
portance because of slightly higher operative risk com-
pared with separate valve-ascending graft procedures.
Composite mechanical valve (St. Jude or Medtronic)
graft prostheses require the patient to receive lifelong
oral anticoagulation with Coumadin to lessen throm-
boembolic complications. The inherent risks of lifelong
oral anticoagulation are not benign and have been pre-
viously described, including thromboembolism from
inadequate drug levels and bleeding complications from
excessive or even therapeutic drug levels.
Elephant Trunk
The elephant trunk procedure was first introduced
by Borst of Germany.^ It involves complete graft re-
placement of the aortic arch in patients with aneurys-
mal changes also affecting the descending thoracic or
thoraco-abdominal aorta. A short segment of the
dacron graft is left dangling in the proximal descend-
ing thoracic aorta in anticipation of a planned second
staged operation to replace the distal aneurysm. Sev-
eral technical advantages are gained during the sec-
ond operation. Survival rates following "completion
elephant trunk" procedures are expectedly not as good
as those in patients who need to undergo only a single
operation to repair thoracic aortic aneurysm.
Adjuncts for Hemostasis
Operations incorporating the use of PHCA to pre-
vent neurologic complications may be associated with
intraoperative coagulopathy. Two antifibrinolytic
drugs, Amicar and tranexemic acid, have been used
to prevent fibrinolysis during cardiac surgery. They
should be given prior to onset of cardio-pulmonary
bypass to achieve optimal effects.
Aprotinin (trasylol) is a serine-protease inhibiting
protein that has been used extensively in the United
Kingdom and increasingly in the United States during
complex cardiovascular procedures to enhance clot-
ting properties and prompt acquisition of surgical he-
mostasis.
If used on cases in which profound hypothermia
has been employed, it is considered important that
intraoperative Heparin levels be monitored by the per-
fusion team to assure adequate intraoperative antico-
agulation on cardiopulmonary bypass. An increased
incidence of disseminated intravascular coagulation has
been reported by authors using aprotinin on cardio-
vascular procedures when Heparin levels were not
monitored. Aprotinin invalidates the activated clotting
time. Other untoward effects include a definite slight
increase in postoperative renal failure requiring he-
modialysis and anaphylaxis in those patients previ-
ously exposed to the drug. It is acceptable practice to
begin aprotinin during the rewarming phase of a deep
hypothermia case or post-operatively in a "rescue"
fashion to reduce bleeding.
Comment
Decreasing the unfavorable natural history of pa-
tients afflicted with proximal aortic dissection and/or
ascending-arch aneurysm begins with proper initial
diagnosis. Acute proximal "dissections" are taken to
the operating room as soon as the diagnosis is con-
firmed. Chronic aortic dissection (greater than 14 days
from onset) of the ascending aorta and/or arch is man-
aged in a similar manner to degenerative aneurysmal
disease in these segments. If the aortic dilatation is
greater than or equal to 5.5 cm., an elective surgical
repair is considered, especially in younger, good risk
patients. Those patients with aneurysms smaller than
5.5 cm., in good health, are followed with serial sur-
veillance imaging studies, usually CT scans or MRI.
Individuals with aneurysms greater than 5.5 cm. but
serious accompanying co-morbidities may be managed
expectantly until the diameter increases further or
symptoms develop, with the understanding that
life-threatening rupture or dissection can occur.
Although corrective surgery remains a formidable
undertaking for patient and surgeon, expected out-
comes have steadily improved. Early survival rates in
specialty centers are in the 90-97% range, depending
on etiology, extent of aneurysm or dissection, patient
co-morbidities, and experience of the physician and
nursing care providers.
Bibliography
1. Johnston KW, Rutherford RB, Tilson MD. Prepared by
the Ad Hoc Committee on Reporting Standards, Society for
Vascular Surgery/North American Chapter, International So-
ciety for Cardiovascular Surgery. Suggested standards for
reporting on arterial aneurysms. J Vase Surg 1991; 13:452-458
2. Crawford ES. The Diagnosis and Management of Aortic
Dissection. JAMA Nov 21, 1990; Vol 264, No 19:2537-41
3. Aortic Surgery Symposium V, panel discussion. April
25-26, 1996. New York, New York
4. Coselli JS, Crawford ES, Beall AC Jr, Mizrahi EM, Hess
KR, Patel VM. Determination of brain temperature for safe
circulatory arrest during cardiovascular operation. Ann
Thorac Surg 1988; 45:638-42
5. Svensson LG, Crawford ES, Hess KR, Coselli JS, Raskin
5. Shenaq SA. Deep hypothermia with circulatory arrest.
Determinants of stroke and early mortality in 656 patients. J
Thorac Cardiovasc Surg 1993; 106:19-31
6. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka
K. Surgical treatment of aneurysm or dissection involving
the ascending aorta and aortic arch, using circulatory arrest
and retrograde cerebral perfusion. J Cardiovasc Surg 1990; 31:553-8
7. Borst HG, Walterbusch G, Schaps D. Extensive aortic re-
placement using "elephant trunk" prosthesis. J Thorac
Cardiovasc Surg 1983; 31:37-40
Volume 93, Number 10 - March 1997
483
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medical professionals in Arkansas?
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484
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Loss Prevetttion
Needed - Documentation in Quotation Marks
J. Kelley Avery, M.D.*
Case Report
In our best efforts to do what is clinically appro-
priate, we can, and do, rely too much on our recall of
the sense of a conversation with a patient, a nurse, or
even a colleague rather than on verbatim documenta-
tion. Such verbatim documentation is not always easy
to come by because of the particulars of a situation in
which we may find ourselves. We may be in the room
with a very sick patient, or on the telephone giving
instructions to a patient or a parent about a sick child,
or in the emergency room (ER) on a busy shift. Wher-
ever we are, unless there is verbatim documentation
sometimes the conversation with a person or the in-
structions given, when reconstructed later, can dis-
tort the picture of what really happened.
A mentally retarded man was brought to the ER
after midnight. The history obtained from friends was
that the patient had been involved in a fight and had
been struck over the head several times by the adver-
sary with a stick. The patient appeared intoxicated,
and in fact had a blood alcohol level over twice that
considered to be legal evidence of intoxication.
The patient was almost impossible to control. He
got up off the stretcher several times, walked about in
the ER, and had to be escorted back to his place by the
nursing staff. On physical evaluation, the man's vital
signs were unimpressive except for an initial blood
pressure of 146/110 mm Hg. This changed in about 20
minutes to 132/94 mm Hg. The initial reading was at-
tributed to the patient's restlessness and agitation.
Neurologically, the patient seemed in command of his
faculties to the extent expected of an intoxicated and
injured emergency patient. He responded appropri-
ately to questions and followed simple commands. He
appeared to be oriented as to time, place, and person.
He claimed no memory of the altercation and the in-
jury that brought him into the ER. It was noted that
while his pupils reacted normally and were of equal
size, there was some constant external deviation of
the left eye, which both the patient and those who
* Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Co., Brentwood, TN. This
article appeared in the July 1994 issue of the Journal of the
Tennessee Medical Association. It is reprinted with permission.
accompanied him said had been present all of his life.
There were contusions over the occipital region, along
with a small laceration in this area. Some blood in the
right ear canal obscured the tympanic membrane, rais-
ing the question of a basilar skull fracture. The nature
of the injuries and the possibility of the fracture were
of sufficient concern for the ER physician to think that
neurologic evaluation and observation in a level I
trauma center were indicated.
On contacting the medical center, the ER physi-
cian had a conversation with the neurosurgical resi-
dent about his patient and the possible need for more
skilled care than was available at the community hos-
pital some distance away. The consultant in the cen-
ter told the attending ER physician that the center was
extremely busy and that the CT was "backed up." He
urged that, if possible, the scan be done locally and
that the results of that examination be made known to
him. At that point, the case would be discussed in the
light of the CT examination and transfer decided on at
that time.
While the physician was on the phone with the
trauma center, the patient became much more agitated,
aggressive, and somewhat belligerent. On reevalua-
tion, the patient's left pupil was beginning to widen
and his level of consciousness began to decrease.
Twenty minutes after the first phone call, the same
neurosurgical consultant was contacted and told of the
change in status of the patient. Authorization was given
for immediate air transport. The patient was intubated
for transport, and about 90 minutes elapsed between
the time the decision to transfer was made and the
patient's arrival at the center, 2-1/2 hours after his ad-
mission to the community hospital ER.
On arrival at the center, the patient was on full
respirator support and deeply comatose. A CT exami-
nation revealed a large right-sided epidural hematoma
requiring emergency surgery and decompression. Post-
operative support included a tracheostomy and a jeju-
nal feeding tube. He continues to function at the brain
stem level.
A lawsuit was filed alleging a failure to transfer to
an appropriate facility in a timely fashion, causing se-
vere and permanent brain injury.
Volume 93, Number 10 - March 1997
485
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Loss Prevention Comments
Although only a relatively small settlement was
required in this case, the issues raised are very perti-
nent to many different areas of our professional lives.
The allegations of a failure to do something in a "Hmely
fashion," resulting in some injury that would not have
occurred had the action been taken in a more "timely
manner," are increasing in frequency and severity.
These charges can and do involve us no matter what
our field of practice might be.
The essence of this issue was that the attending
ER physician believed that in recommending the CT
be done locally because the machine in the level I
trauma center was "backed up," the receiving physi-
cian was refusing to accept the patient at that time.
He testified to this belief in pretrial discovery deposi-
tion. The neurosurgeon, on the other hand, testified
that he never refused transfer at any time. On the
record it became apparent that the two physicians in-
volved in the transfer decision were at odds as far as
their memory of events was concerned.
Documentation on both ends of the transfer was
brief, and could support either view. On the transfer-
ring end of the conversation, there was not any re-
corded evidence that would support the testimony of
the doctor in the community hospital ER. There was
not a statement that "neurosurgical consultant denies
transfer until after CT done." On the receiving end,
the same is true. It would have been helpful if the
neurosurgical consultant had documented "since our
CT is backed up at the moment, collective decision
made to expedite the CT at local facility if time and
condition of the patient allow." The lack of this kind
of descriptive documentation on both ends of this con-
versation allowed the plaintiff to contend that the com-
munity hospital's ER physicians had delayed the ac-
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The settlement was relatively small, but the issues
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CODING VIOLATIONS AND CONSIDER FRAUD AND ABUSE CHARGES AGAINST PHYSICIANS.
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CLINICOPATHOLOGICAL
A W ^ ^ ^ Clinicopathological Images, a new one-page feature
I section of clinical/pathology photos with a brief de-
B -A- ▼ ^ ^ ^ ^ scription, will appear in The Journal quarterly.
Clostridium Difficile Pseudomembranous Enterocolitis is a descriptive entity of the gross findings of white
and yellow surface plaques due to various antibiotic use, mediated by 2 toxins (A-enterotoxin, B-cytotoxin), that
induce fluid flux, membrane permeability and intense mucosal inflammation and even ulcerations with diarrhea.
Diagnosis is accomplished by identifying the toxins in the feces or by the latex-agglutination test or culturing the
organism. Therapy includes metronidazole or vancomycin.
This patient presented with severe bloody diarrhea and toxic megacolon who underwent a colectomy reveal-
ing extensive green pseudomembranes with erythematous mucosa (picture A); under low power view note the
diverticulum with typical "exploding" lesion (picture B); and under high power view the exploding crypts with
pseudomembrane formation composed of fibrinant acute inflammatory cell (picture C).
Authors:
*Nick Paslidis, M.D., Ph.D., is Clinical Assistant Professor with the Department of Internal Medicine at UAMS in Little Rock. He also
is affiliated with the White River Rural Health Center in Carlisle, Arkansas, and formerly with the Division of Gastroenterology at
Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
*Carlos Torres, M.D., is with the Department of Pathology at Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Volume 93, Number 10 - March 1997
489
Cardiology Commentary andUpdate
J. David Talley, M.D.*
Vito Calandro, M.D.*
Tracy Dietz, M.D.*
Ha Dinh, M.D.*
Stress Electrocardiography: A Review
A stress electrocardiogram (ECG) is a non-invasive
test used to evaluate cardiac function. Recently we
cared for a patient who presented with symptoms char-
acteristic but not pathognomonic of myocardial is-
chemia who had a positive stress ECG. We review the
salient features of this diagnostic modality. This re-
view has been recently published.'
Patient Report
The patient is a 57-year-old male with a history of
dull achy chest discomfort associated with shortness
of air occurring with exertion and at rest. He had sys-
temic arterial hypertension and prior cigarette use (see
complete problem list. Table 1). The
patient's brother underwent coronary
artery bypass graft (CABG) surgery in
his early 50's. The ECG at rest showed
sinus bradycardia and tiny q-waves in
the inferior leads.
The patient exercised for 10 minutes
on a standard Bruce protocol achieving
11 metabolic equivalent test (MET) units
and a double product of 26,390 (peak
heart rate of 145 bpm, 90% of
age-predicted maximal heart rate and a
peak blood pressure of 182/90). At peak
exercise there was greater than 1 mm of
horizontal ST segment depression in the
inferior-lateral leads.
Cardiac angiography showed an 80%
diameter stenosis of the ostial portion of the left main
coronary artery (Figure 2) and a 50% stenosis of the
mid-right coronary artery. The left ventricular func-
tion was normal. He underwent CABG surgery utiliz-
ing the left internal thoracic artery which was anasto-
mosed to the left anterior coronary artery and reverse
saphaneous vein grafts were anastomosed to the sec-
ond marginal and posterior descending arteries. His
post-operative course was unremarkable.
* Drs. Talley, Calandro, Dietz and Dinh are with the Division of
Cardiology, Department of Internal Medicine, at UAMS.
Indications, Contraindications, and Complications of
Stress Electrocardiography
A stress electrocardiogram is used to detect and
quantify coronary artery disease, assess functional ca-
pacity, monitor therapeutic response to cardiac medi-
cations, and to evaluate cardiac rhythm.^ Careful at-
tention to the indications and contraindications for
doing stress electrocardiography (Table 2) and moni-
toring the patient during the examination will reduce
the complications of the test. In a series of more than
500,000 stress electrocardiograms, complications in-
cluded one death, four myocardial infarctions, and 50
life threatening arrhythmic events per 10,000 tests done.
These complications are more common in patients who
undergo the procedure soon after myocardial infarc-
tion or as a method to evaluate ventricular
arrhythmias.^
Terminology in Stress Electrocardiography
An understanding of principles of exercise physi-
ology and statistical terms used in analysis of stress
electrocardiography is essential to comprehend and
properly interpret the test. Definitions of commonly
used terms are in Table 3.
Table 1 - Complete Problem List
Coronary Artery Disease
Etiology: Atherosclerosis
Anatomy: A. Cardiac Catheterization (2/3/97): 80% left main,
50% mid right coronary artery
B. CABG surgery (2/6/97): Left ITA->LAD, RSVG-^OM2,
RSVG->PDA
Physiology: A. Presentation with angina pectoris
B. Cardiac catheterization (2/3/97): normal LV function
Functional Capacity:
Objective Assessment:
compromised
Class I at presentation, now assymptomatic
Severe disease at presentation, now mildly
2. Systemic Arterial Hypertension
3. Substance Use
A. Prior cigarette use, discontinued
490
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table 2 - Indications and Contraindications
for Performing Stress Electrocardiography
Indications
Contraindications
Absolute
Relative
evaluate symptoms of coronary artery
disease
acute myocardial infarction
within 3 to 5 days
left main or equivalent
coronary artery disease
quantify the extent of coronary artery disease
unstable angina pectoris
moderate or severe valvular
stenosis
assess functionai capacity
uncontrolled arrhythmias
electrolytic abnormality
monitor therapeutic response to cardiac
medications
acute cardiac infection
significant pulmonary or
systemic arterial hypertension
evaluate the cardiac rhythm response to
exercise
symptomatic severe aortic
stenosis
hypertrophic cardiomyopathy
uncontrolled congestive heart
failure
depressed mental acuity
acute pulmonary embolus or
Infarction
2nd or 3rd degree
atrioventricular block
non-cardiac conditions that
effect or aggravate exercise
performance
physical disability that
precludes a safe test
lower extremity thrombosis
Modified from: Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML Exercise standards: a
statement for health care professionals from the American Heart Association. Circulation 1995; 91:580.
Methods
The Patient. The patient should be fasting for at
least two hours before undergoing a stress electrocar-
diogram. The indications, methods, benefits, and limi-
tations of the test should be fully discussed with the
patient before the procedure. Informed, written, and
witnessed consent should be obtained. A history (in-
cluding medications) and physical examination of the
cardiovascular system is done. A physician, or trained
assistant with direct physician oversight, supervises
the procedure. During the test, the patient's symp-
toms and signs (heart rate, blood pressure, cardiac
examination) and the electrocardiogram (ST segments,
conduction abnormalities, and arrhythmias) are closely
monitored at each level of exercise. When the end-
point of the test is reached, monitoring is continued
until the patient is asymptomatic and vital signs have
returned to baseline values.
Type of exercise. The patient should be able to exer-
cise for the stress electrocardiogram to have diagnos-
tic quality. An inadequate exercise level decreases the
specificity of the test dramatically. Recognizing the
patient's physical limitations and conditioning are im-
portant so that an appropriate type of exercise can be
prescribed.
A stress electrocardiogram measures the relation-
ship of myocardial oxygen demand and supply to the
heart. Most commonly, demand is increased with
physical exercise and therefore increases heart rate and
myocardial contractility. Demand may be increased by
exercise of either the lower or upper extremities or
with the use of other modalities. A stress test using a
motor driven treadmill or bicycle ergometry is the pre-
ferred method of doing lower extremity stress electro-
cardiography. Walking is easier than cy-
cling and more commonly results in a
satisfactory exercise response. Usually,
an averaged conditioned adult patient
without significant physical limitations
can undergo a stress electrocardiogram
using a standard Bruce protocol (Figure
3). In this protocol, the speed and in-
cline of the motor driven treadmill is in-
creased every three minutes. Less
strenuous lower extremity exercise pro-
tocols (Balke and Naughton) are pre-
scribed for poorly conditioned patients.
Myocardial oxygen demand may
also be increased with arm ergometry,
noninvasive pacing, and intravenous
dobutamine infusion. These methods
are used for an inadequate physiologi-
cal response or physical limitation to
lower extremity exercise. They are usu-
ally combined with radionuclear angiog-
raphy, echocardiography, or nuclear
scintigraphy to enhance diagnostic accuracy.
The distribution of myocardial oxy-
gen supply can be altered with coronary
vasodilators such as dipyridamole and adenosine.
These agents dilate normal but not atherosclerotic ar-
teries thereby shunting blood toward normal tissue
and away from ischemic zones. Complementary im-
aging techniques are also used with this procedure.
Factors Which Modify Stress Electrocardiographic ST
Segment Changes
A 12 lead stress electrocardiogram is the standard
test done to detect coronary artery disease. The speci-
ficity of the test is decreased in pre-menopausal fe-
males, patients with mitral valve prolapse, and pa-
tients with left ventricular hypertrophy and resting
ST-T wave abnormalities. In these instances, use of a
supplemental imaging modality (myocardial perfusion
or echocardiography) is recommended. False-positive
stress electrocardiography is also seen in patients with
hypokalemia or receiving cardiac glycosides or psy-
chotropic medications. The electrolyte abnormality
should be corrected and the medications stopped for
one week, if possible, before the test.
Endpoints. Three endpoints are used in stress elec-
trocardiography to evaluate cardiac function: 1 ) symp-
toms and 2) signs of maximal exercise capacity, and 3)
diagnostic electrocardiogram changes. Symptoms sug-
gesting maximal exercise capacity are increased chest
or leg pain, exhaustion, dyspnea, unsteady gait, cy-
anosis, pallor, or the patient's desire to stop the test.
A symptom limited endpoint of stress electrocardio-
graphy usually produces increased specificity of the
test due to heightened exertion. Signs of maximal oxy-
gen consumption are indirect and include a maximal
predicted heart rate or MET units (Table 2 and Figure
3). For a heart rate or MET limited test to be diagnostic.
Volume 93, Number 10 - March 1997
491
Table 3 - Standard Definitions
in Stress Electrocardiography
the exercise level must be near maximal for the test to
have appreciable specificity. Five electrocardiographic
characteristics are assessed during a stress electrocar-
diogram: the degree, slope, time of onset and dura-
tion of ST segment changes, and the presence of ven-
tricular arrhythmias.
Interpretation of Results
Proper interpretation of a stress electrocardiogram
requires precise understanding of the continuous and
inverse relationship between sensitivity and specific-
ity. A symptom limited stress electrocardiography is
highly correlated with the presence of coronary artery
disease. Patients who are asymptomatic have less than
a 10 percent incidence of coronary artery disease, com-
pared to more than a three-fourths occurrence if the
patient develops angina pectoris during the test.^
Changes in the electrocardiogram may be charac-
teristic of myocardial ischemia or injury and are corre-
lated with a long term cardiovascular event (Figure
4).^ The length of the PR segment is a balance between
sympathetic and parasympathetic tone and therefore
may shorten, remain the same, or lengthen. The slope
of the ST segment is analyzed 0.08 second after the J
point (Figure 5). The slope may remain at the baseline,
have downward, horizontal, or upward depression,
or be elevated above the baseline. A normal response
to exercise is a ST segment that remains level with the
baseline. Downward sloping ST segment depression
is a highly specific marker of severe multiple vessel
coronary artery disease.^ Horizontal and up sloping
ST segment changes suggest less extensive coronary
artery disease. ST segment elevation is seen with epi-
cardial injury, left ventricular aneurysm, or pericardi-
tis. There is no correlation of ST segment depression
and location of the responsible coronary lesion. ST
segment elevation is a useful guide to underlying coro-
nary artery anatomy. T wave inversion is commonly
seen with exercise and is a nonspecific marker of sig-
nificant coronary artery disease. Inversion of the
u-wave is an insensitive, but a very spe-
cific finding for a critical stenosis of the
left anterior descending coronary artery.
As noted in Figure 3, the amount of ST
segment depression, slope of the ST seg-
ment, time to onset and duration of ST
segment changes are correlated with
long-term cardiovascular events.
A variety of arrhythmias can be seen
during exercise. Atrial arrhythmias are
common, seldom hemodynamically sig-
nificant, and usually revert to normal in
the post exercise period. Isolated ven-
tricular beats may also be observed and
do not signify coronary artery disease.
Sustained or complex ventricular ectopy
is seen in less than 1% of all patients
undergoing stress electrocardiography
and may occasionally require pharma-
cological or electrical therapy. These life threatening
arrhythmias suggest the need to define the extent and
severity of coronary artery disease and left ventricular
dysfunction.
References
1. Talley JD. Stress Electrocardiography. In: Hurst JW, ed.
Medicine for the Practicing Physician, 4th ed. Samford, CT:
Appleton & Lange, 1996,2061-2064.
2. Schlant RC, Blomqvist CG, Brandenburg RO, et al. Guide-
lines for exercise testing: A report of the American College
of Cardiology/ American Heart Association task force on as-
sessment of cardiovascular procedures (subcommittee on
exercise testing). J Am Coll Cardiol 1986;8:725.
3. Stuart RJ Jr., Ellestad MH. National survey of exercise
stress testing facilities. Chest 1980;77;94.
4. Goldschlager N. Use of the treadmill test in the diagnosis
of coronary artery disease in patients with chest pain. Ann
Intern Med 1982;97:383.
5. Weiner DA, McCabe CH, Ryan TJ. Prognostic assessment
of patients with coronary artery disease by exercise testing.
Am Heart J 1983;105:749.
6. Goldschlager N, Selzer Z, Cohn K. Treadmill stress tests
as indicators of presence and severity of coronary artery dis-
ease. Ann Intern Med 1976;85:277.
Figure 1. The patient exercised for 10 minutes on a stan-
dard Bruce protocol achieving 11 metabolic equivalent
test units (MET, peak heart rate of 145 bpm, 90% of
age-predicted maximal heart rate and a peak blood pres-
sure of 182/90). At peak exercise there was greater than 1
mm of horizontal ST segment depression in the
inferior-lateral leads.
Statistical Analysis
Exercise Physiology
sensitivity
true-Dositive
all patients with coronary
disease
MET = metabolic
equivalent test
3.5 ml OVkg/min
specificity
true-neaative
all patients without coronary
disease
= maximum
ventilatory oxygen
consumption of the
patient
maximum cardiac
output X maximum
arteriovenous
difference
positive predicative
value
true-DOsitive resoonses
ail positive responses
MPHR - maximal
predicted heart rate
female = 216 bpm -
0.88 x age
male = 204 bpm - 0.6
X age
negative predicative
value
true-neaative resoonses
all negative responses
MOj = myocardial
oxygen uptake
estimated by double
product = heart rate x
systolic blood pressure
Bayes' theorem
the index of suspicion (pretest
probability) that the disease is
present
492
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Figure 2. A coronary angiogram in the left anterior oblique posi-
tion revealing an 80% stenosis of the osteal portion of the left
main coronary artery (arrow).
Nomenclature for Determination
of ST'Segment Abnormalities
B = J point
C = 80 msec from J point
0-E = 2 mm ST-segment
depression
F = tsoeiectric line
Patterns of Myocardial Ischemia
Upsloping
Elevation
Figure 5. Criteria for determination and types of ST segment
changes in stress electrocardiography. The slope of the ST seg-
ment is determined 0.8 second after the J point, and may be
directed downward, horizontal, or upward. ST elevation may
also be seen. (From Brachfeld N. ECG exercise tolerance test:
interpretation of results. Primary Cardiology November 1984,
page 35).
hy U4I
Minutes Speed
per and
Test Name Stage Grade
1.6
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Ellestad
3-2-2-3
mph
Ve grade
1.7
10V.
3
10V.
4
10%
5
10%
Bruce
3
mph
% grade
1.7
10V.
! 2.5
1 12%
3.4
14 V.
4.2
16%
Balke II
2
mph
% grade
3.4
2%
3.4
4V.
3.4 3.4
6% 8%
3.4
10%
3.4
12%
3.4
14V.
3.4
16%
3.4
18%
3.4
20%
3.4
22%
3.4
24%
3,4
26%
Balke 1
2
mph
Ve grade
3
OVe
3
23 V.
3
5V.
3
7iV.
3
10%
3
12.5%
3
15%
3
17.5%
3
20%
3
22.5%
Naughton
2
mph
Ve grade
OVo
2
OVe
2
3.5 V.
2
7Ve
2
10.5 V.
2
14%
2
17.5%
MET
1.6
2
3
4
5
6
7
8
6
10
11
12
42
13
14
15
16
Oxygen use (ml/mln/kg)
5.6
7
10.6
14
17i
21
24.5
26
31.5
35
38.5
45.5
49
52.5
56
Functional Class (AHA)
IV
III
II
1
Figure 3. Standard protocols used in stress electrocardiography and their con-
version to metabolic equivalent test units, oxygen use, and functional class. Ab-
breviations: AHA = American Heart Association, MET = metabolic equivalent
test. (From Brachfeld N. The electrocardiographic exercise tolerance test: meth-
ods and procedures. Primary Cardiology November 1984, page 25).
AMOUNT ST SESMENT^
cofFKumnoN
(n=72)
I I I I I
amnON ST SEQUENT*
'^i
0-2n»
(r>=173)
3-5min
(rF62)
26min
(n*57)
I i I I I I I I I I I I
0 12 24 36 48 60 12 24 36 48 60
« T MONTHS . , ,
Figure 4. Long term survival of patients
based on the amount, configuration, time
of onset, and duration of ST segment de-
pression. (From Weiner DA, McCabe CH,
Ryan TJ. Prognostic assessment of patients
with coronary artery disease by exercise
testing. Am Heart] 1983;105:749, with per-
mission).
Family physician faculty - Medical Director for university-
based occupational medicine/preventive medicine clinical
program. Duties; patient care, administration and teaching.
Medical Director for medical school’s Student and Employee
Health Service; Executive Assessment Program, and
primary care Occupational Health Care Clinic. Opportunity
to teach and faculty appointment. Must be family practice
residency trained with interest in occupational
medicine/preventive care. Send CV and statement of
interest to; Geoffrey Goldsmith, MD, MPH, Department of
Family and Community Medicine, 4301 West Markham, Slot
530, Little Rock, Arkansas 72205-7199.
FOR LEASE
3,032 sq. ft. medical clinic building near Conway
Hospital. Located in medical complex area at
2515 College Avenue in Conway, Arkansas.
Call Roger Price at:
College Pharmacy - 501-327-8088 or
Home, after 7 p.m. - 501-329-8507
Volume 93, Number 10 - March 1997
493
AS hasirmrn iimvf ij U pioneers U L C
foimd^anirnuU as esotir as ilie
buffaiu. prairie dogs, bean, beaverf/iighnrrr ' ^
ilirep, cougars, wolves and ratdesrfciMa.
The eagle became a national symbol. < ) "
^ I he eagle becany a national symbol. < ) " ~ • /
£ykjJM^OH^ w ^tZc/OK^ 2t
OiyjjJ ^
<9iyu^
thank you
tn made it
have a
yi I had no
a ; did not
sucliofOg^""
.rdedP-'Og'-'""
la like to S(i
^ould IiK
^11 Your pros
„ i, a much
'Thnnks aguin
" rnedical
blessed Wit,
^^^^P^ogram.
'^^ndhelpfui
me.
r^ttentioi
^owledi
There wer
^oopleto.
ror more
information
on how
you can help,
call AHCAF at
(501) 221-3033
r (800) 950-8233
Arkansas Health Care
Access Foundation, Inc.
Hr those physicians who volunteer ^
w through the Arkansas Health m
I Care Access Foundation, 1
Thank You!
As you can see from a sampling of
\y\pyp\.:
i letters we have received, your
Hjt involvement in our program Is"' A
Hk appreciated and in many jM
^^^^^pases life-saving,
St^^tc WdMh WMcIi
Information provided by the Arkansas Department of Health, Division of Epidemiology
Influenza Update
Arkansas - Through early February 1997, the Ar-
kansas Department of Health has obtained 12 positive
influenza cultures. All were type A, subtype unknown.
Counties with lab-confirmed flu are Arkansas, Ashley,
Bradley, Garland, Greene, Lafayette, Mississippi,
Montgomery and Pulaski.
United States - Influenza morbidity peaked between
mid-December and early January and has declined
since that time. Preliminary data from the CDC's sen-
tinel physicians suggest that influenza-like illness in
the U.S. has returned to baseline levels. For the week
ending January 25 (week 4), epidemiologists in 11 states
reported "widespread" activity. Twelve states, includ-
ing Arkansas, reported "regional" activity and 26 states
reported "sporadic" activity. One state did not report.
For most of the influenza season, influenza type
A accounted for 97-100% of the isolates reported in the
U.S. overall. However, during the week ending Janu-
ary 4 (week 1), the proportion of influenza type B iso-
lates began to increase, reaching 15% by week
Based on reports received from 121 cities, 8.8% of
all deaths reported by the vital statistics offices in 121
U.S. cities, during week 4 were attributable to pneu-
monia and influenza. This marks the seventh consecu-
tive week that percentages have exceeded the epidemic
threshold of 7.3%.
For more information on influenza or to report
outbreaks, call the Arkansas Department of Health,
Division of Communicable Disease & Immunization
at (501)661-2784 or the Communicable Disease Report-
ing System at (800)482-8888.
HELP PUT
A SMILE ON
MY FACE
LET'S FIND CURES FOR
NEUROMUSCULAR DISEASES.
MUSCULAR DYSTROPHY ASSOCIATION
(800) 572-1717
Volume 93, Number 10 - March 1997
495
Reported Cases of Selected Diseases in Arkansas Profile for December 1996
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due to the effects
of late reporting. The numbers in the table below reflect the actual disease onset date, if known, rather than the date the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
Dec. 1996
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
1995
Total
Reported
Cases
1994
Campylobactehosis
10
240
153
187
Giardiasis
20
183
131
126
Shigellosis
19
176
176
193
Salmonellosis
22
454
332
534
Hepatitis A
36
508
663
253
Hepatitis B
4
86
83
60
HIB
0
0
6
5
Meningococcal Infections
2
33
39
55
Viral Meningitis
3
36
31
62
Lyme Disease
0
26
11
15
Rocky Mountain Spotted Fever
0
22
31
18
Tularemia
0
19
22
23
Measles
0
0
2
5
Mumps
0
1
5
7
Gonorrhea
304
5027
5437
7078
Syphilis
16
706
1017
1096
Legionellosis
0
1
5
16
Pertussis
0
16
59
33
Tuberculosis
45
225
271
264
For a listing of reportable diseases in Arkansas, call the Arkansas Department of Health, Division of Epidemiology, at (501) 661-2893.
496
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Getting Acquainted
Samuel E. Landrum, M.D.
Journal Editorial Board Member
Dr. Samuel E. Landrum, a Fort Smith general surgeon, is one of six editorial
board members for The Journal of the Arkansas Medical Society. By submitting numer-
ous editorials and reviewing many scientific articles for publication consideration.
Dr. Landrum has contributed greatly to the quality of The Journal.
Dr. Landrum has been a member of the AMS for thirty-two years. To him,
being an active member means having a competent voice in issues that come before
the legislature and a joint concern for communicable disease and social issues as
they effect people's health. He believes the most important issue facing the AMS is
keeping an emphasis on the needs of patients and the so called health industries.
Dr. Landrum's journey in the medical field began in 1956 when he received his
doctoral degree from the University of Tennessee College of Medicine. He then
traveled to Tuscaloosa, Alabama, where he trained at Druid City Hospital. From
1957 through 1961, he trained at the Henry Ford Hospital in Detroit, Michigan.
Finally in 1961, he landed in Arkansas where he served in the U.S. Army
Medical Corps at Ft. Chaffee. In 1962, he was board certified in surgery and, in
1963, received his license to practice in the state of Arkansas - which he has done
ever since.
As far as the future is concerned. Dr. Landrum is very optimistic and challeng-
ingly looks forward. In his May 1996 editorial entitled "Good Times are Coming,"
Dr. Landrum mentions a couple of notable medical improvements that took place
while he was a medical student.
"The polio vaccine was announced when we students were in class, and it
brought our hearts a swelling of joy...," he wrote. "Similarly, we were exhilarated
when a professor told our class that it had just been found that corticosteroid
therapy was allowing children with leukemia to live six months instead of dying in
a very few weeks."
He continued his editorial by listing some good things he believes "will come
along soon to the benefit of patients and surprisingly the pleasure of practicing
physicians." After reading Dr. Landrum's editorial, it is quite obvious that previ-
ous medical improvements along with hope have lead him to view the medical
field with buoyancy and courage.
In addition to many professional affiliations. Dr. Landrum served from 1980 to
1983 on the AMS Member Peer Review Committee. Since 1977, he has been Chair-
man of the District Professional Relations Committee for the AMS. He is a fellow of
the American College of Surgeons and has served in the Arkansas Chapter as
secretary/treasurer (1982-83), vice president (1984-85) and president (1986-87). In
1976, he was honored with the Trauma Achievement Award by the American Col-
lege of Surgeons' Committee on Trauma. From 1974 through 1977, he was ap-
pointed Chairman of the Governor's Council on EMS.
Dr. Landrum was born January 16, 1935, in Martin, Tennessee. He is married
to Annette, a retired pathologist, who is now the Medical Director of Sparks Re-
gional Medical Center. They have four children who are now scattered from Los
Angeles to Amsterdam. Their son is the manager of European Operations for a
manufacturing company; their oldest daughter practices internal medicine in
Springdale; their youngest daughter is a senior financial officer for an international
company and their other daughter, an electrical engineer, is rearing their youngest
grandchild and raising ostriches and emu.
Hobbies: Travel, dancing
and an amateur interest
in the stock market.
If I had a different job.
I'd be: A teacher.
The person I most
admire: My wife, Annette
V. Landrum, M.D.
Best Habit: Showing up
on time.
Worst Habit: Procrastination.
One of my pet peeves:
Pretentiousness.
Favorite book, television
show and/or movie: My
favorite book is any book
of Anne Tyler's. Frasier is
currently my favorite
television show and my
favorite movie is Stalag 17.
The turning point of my
life was: When the Army
Medical Corps drafted me
and assigned me to Fort
Chaffee, Arkansas.
When I was a child, I
wanted to grow up to be:
A doctor.
My philosophy of life: To
prepare, treat people
fairly and work hard.
One word to sum me up:
Compulsive.
Volume 93, Number 10 - March 1997
497
ARKANSAS MEDICAL SOCIETY
1997 ANNUAL CONVENTION
ARLINGTON HOTEL ♦ HOT SPRINGS, ARKANSAS
NEW HEIGHTS
FRIDAY, MAY 2, 1997 (CON'T)
Shuffield Lecture/Luncheon
Speaker: Congressman Vic Snyder, MD
Exhibit Center Open
Refreshments
Grand Prize Drawings
Second Feature Session
"Ethical Issues in Managed Care:
A Practical Action Plan ”
Hospitality Hour
Inaugural Banquet
President's Reception
& Dance
SATURDAY, MAY 3, 1997
Council Meeting (Tentative)
Early Morning Refreshments
Third Feature Session
"Legislative Report from the
81st General Assembly”
House of Delegates
Specialty Meetings
Arkansas Academy of Family Plysicians
Arkansas Urologic Society
Arkansas Pathdogy Society
WATCH YOUR MAIL FOR
REGISTRATION A\ATERIALS
Radiological Case
of the Month
David Marshfield, M.D., Editor
Authors
George W. Christy, M.D.
David Marshfield, M.D.
History:
The patient is a 67-year-old male who was referred for evaluation of peripheral vascular disease. He has known
coronary disease and underwent coronary artery bypass grafting in June of 1995. His peripheral vascular disease
had been asymptomatic until January of 1996. He was seen in evaluation at a Dallas/Fort Worth hospital and had
aorto-bifemoral bypass surgery recommended. The patient now presents for a second opinion.
Figure 1
Figure 2
Angiographic findings:
The angiogram revealed a long segment (4 cm. length) occlusion of the right common iliac artery (figure 1).
There was reconstitution of flow at the level of the right common femoral with no evidence of significant distal disease
(figure 2). His left external iliac had a complex, ulcerated, 95% lesion at its distal portion with no significant distal
disease (figure 1).
Volume 93, Number 10 - March 1997
499
Bilateral Iliac Artery Atheroscerosis treated with Balloon
Angioplasty and Stent Placement
Figure 3 Figure 4
Diagnosis:
Bilateral Iliac Artery Atheroscerosis treated with Balloon Angioplasty and Stent Placement
Discussion:
Access was obtained in a retrograde fashion via both right and left common femoral arteries. A .035 inch Wholey
wire was advanced retrograde through the left femoral artery sheath over the bifurcation and across the 100% occlu-
sion of the right iliac artery. A .035 Terumo wire was exchanged for the Wholey wire and advanced through the 100%
occlusion and externalized via the right common femoral artery sheath. A 5 French multi-purpose catheter was
advanced retrograde over the Terumo wire through the right arterial sheath to the bifurcation. The Terumo wire was
removed and a second .035 Wholey wire was advanced through the multi-purpose catheter to reside in the mid-
aorta. Two, 7cm. by 4 mm. Match 35 Schneider balloon catheters were advanced retrograde via the respective
femoral arterial sheaths to the levels of ipsilateral disease and pre-dilatation of both iliacs was achieved (figure 3).
Bilaterally, 8 x 40 mm. Wallstents were advanced through the lesions and positioned at the bifurcation of the aorta.
Then stents were sequentially deployed and, post implant, balloon inflation with an 8 mm. By 4 cm. Blue Max balloon
catheter yielded the final angiographic result (figure 4). There were no complications encountered. Following the
procedure the patient was transferred to the ward. The sheaths were removed and the patient was discharged the
following day. The patient remains asymptomatic.
This case demonstrates alternative to intra-abdominal revascularization surgery. The techniques can be applied
to selected patients and can be completed safely, with very low risk and excellent long-term patency.
Conclusion:
We have extensive experience in inventional angiography with percutaneous balloon angioplasty in general and
specifically in the treatment of focal iliac artery lesions. Focal (short segment) lesions of the iliac artery have a high
technical and clinical success rate when treated with balloon angioplasty alone (without stents). Heretofore, we have
not been particularly successful in treating long segment stenoses or chronic occlusions with angioplasty alone.
Recent research in utilization of intravascular stents indicates there is marked improved patency rate of these com-
plex lesions which historically have had a very low success rate with angioplasty alone. The conclusion arrived at by
Murphy et aP in a recent manuscript was as follows:
500
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
“Technical success and complication rates for percutaneous iliac artery revascularization with use of Wallstents
are favorable, symptoms improved in the majority of patients and excellent secondary patency can be achieved. With
use of Wallstents, most patients with iliac artery insufficiency as a result of long segment disease or chronic occlu-
sions can be treated percutaneously.”
Three years ago, the FDA authorized a phase II, multi-center trial involving 13 institutions which also reported
promising results comparing the Wallstent (which has been used in Europe since 1987, but has not been DDA
approved in the United States) with the Palmaz stent (currently FDA approved in the U.S.) in the iliac system.
Martin et aF, in the Journal of Vascular and Interventional Radiology, published the multi-institutional trial results
in 1995. The indications for stent placement in the iliac system were: 1.) unsatisfactory angioplasty, 2.) complete
occlusions, and 3.) restenosis within 90 days of a previous angioplasty. The mean length of occlusions treated was
6.6cm (range, 1 to 13cm) and the mean length of stenosis was 3.0cm (range, 0.2 to 18cm). The initial procedural
(technical) success rate was 97%. The primary clinical patency was 81 % at 1 year and 7 1 % at 2 years. The second-
ary clinical patency rate was 91% and 86%, respectively. The secondary patency rate refers to patency of a stent
which required a secondary intervention after the original placement procedure.
Long, et aP utilizing the Wall-stent in Europe, reported a primary angiographic patency rate of 85% and a second-
ary patency of 95% at one year in the iliac system. Vorwerk and Gunther^ reported a primary success rate in iliac
occlusions with a 6 month clinical patency of 93%. These researchers initially reported their primary success rate in
crossing occlusions was 70%, however, more recently, their technical success rate has increased to 92% through
greater experience with occluded lesions.
It is clear that there is continuing improvement in stent technology for intravascular uses. Along with advancing
technology, we as interventionalists, are gaining experience, not only in the technical skills of placing intravascular
stents, but just as importlantly, in selecting appropriate lesions. We are no longer limited to short segment lesions but
are now able to achieve high technical and clinical success rates with long segment disease and chronic arterial
occlusions.
Bibliography:
1 . Timothy Murphy, et al. Percutaneous revascularization of complex iliac artery stenosis and occlusions with use of Wallstents.
JVIR 1996;7;21-27.
2. Eric Martin, et al. Multicenter trial of the Wallstent in the iliac and femoral arteries. JVIR 1995;6:843-849.
3. Long AL, Page PE, Raynaud AC, et al. Percutaneous iliac artery stent: angiographic long-term follow-up. Radiology
1991:180:771-778.
4. Vorwerk D, Gunther RW. Mechanical revascularization of occluded iliac arteries with use of self-expandable endoprotheses.
Radiology 1 990; 1 75:41 1 -41 5.
Further Reading:
Zollikofer CL, Antonucci F, Markus P, et al. Arterial stent placement with use of the Wallstent: midterm results of clinical experi-
ence. Radiology 1991;179:449-456.
Author: George W. Christy, M.D., is a Fellow of the American College of Cardiology and a member of the Cardiovascular
Diseases clinic in Little Rock.
Editor of manuscript/Author of conclusion: David Marshfield, M.D., is Director of Radiology at Riverside Imaging Center and
Clinical Associate Professor of Radiology at UAMS.
Volume 93, Number 10 - March 1997
501
In Memoriam
Jerry C. Chapman, Sr., M.D.
Dr. Jerry C. Chapman, Sr., of Cabot died Saturday, January 11, 1997. He was 54. He is survived by his
mother, Mrs. R.B. Chapman of Millington, Tenn.; his wife, Phylis Diane Chapman; one son and daughter-in-
law, Jerry Chalmas (Jace) Chapman Jr. and Stephanie C. Chapman, of Cabot; two daughters and one son-in-law,
Melanye L. Weir and Bradley Weir of Cabot, Lark Buckingham of Cabot; one sister and brother-in-law. Dona Rae
Boyter and James T. Boyter of Austin, Ky.; two grandchildren, Joshua Colbye (JC) and Kyle Lee.
Resolutions
Eaton Wesley Bennett, M.D.
WHEREAS, the members of the Pulaski County Medical Society are saddened to learn of the recent death of an
esteemed member, Eaton Wesley Bennett, M.D.; and
WHEREAS, he was a loyal member of this organization for many years; and
WHEREAS, his love for his country was evidenced by distinguished service in the Army Medical Corps, for
which he was awarded the Bronze Star; and
WHEREAS, Dr. Bennett will be remembered by his peers and patients alike as a caring and competent physician;
BE IT THEREFORE RESOLVED;
THAT, this resolution be adopted and placed in the archives of this Society; and
THAT, a copy of this resolution be sent to Dr. Bennett's family as an expression of our genuine sympathy; and
THAT, a copy be made available to The Journal of the Arkansas Medical Society for publication.
Allen Carruth Hill, M.D.
WHEREAS, the membership of the Pulaski County Medical Society notes with heart-felt sorrow the untimely
death of a respected member, Allen Carruth Hill M.D.; and
WHEREAS, Dr. Hill demonstrated his devotion to medicine by loyal membership in this and numerous other
professional organizations; and
WHEREAS, the compassion and concern that were the hallmarks of Dr. Hill's practice will live on in the minds
of his many patients, friends and colleagues;
BE IT THEREFORE RESOLVED:
THAT, this resolution be adopted and placed in the permanent files of this Society; and
THAT, a copy of this resolution be sent to Dr. Hill's family as a token of our sincere sympathy; and
THAT, a copy of this resolution be made available to The Journal of the Arkansas Medical Society for publication.
William Payton Kolb, M.D.
WHEREAS, the members of the Pulaski County Medical Society observe with heart-felt sorrow the recent death
of one of our most respected and loved members, William Payton Kolb, M.D.; and
WHEREAS, Dr. Kolb was an active and faithful member of this Society for forty-eight years, serving in numerous
positions of leadership including that of President in 1965; and
WHEREAS, Dr. Kolb's concern for his patients and for society at large was manifested through active and
enthusiastic service on behalf of Lions World Services for the Blind, the Arkansas Teenage Suicide Commission,
Pulaski Heights Baptist Church and numerous other civic organizations; and
WHEREAS, Dr. Kolb was a tireless advocate for the advancement of Psychiatry, constantly lobbying state and
national legislators for increased funding and services for the mentally ill; and
WEREAS, Dr. Kolb's life of faith in God and service to others will stand as an enduring example to his fellow men;
BE IT THEREFORE RESOLVED:
THAT, this resolution be adopted and filed in the permanent files of this Society; and
THAT, a copy of this resolution be sent to Dr. Kolb's family as a token of our sincere sympathy; and
THAT, a copy be made available to The Journal of the Arkansas Medical Society for publication.
All Resolutions Adopted By Order of the Memorials Committee
Board of Directors Fred O. Henker, III, M.D., Chairman
January 22, 1997 James W Headstream, M.D.
Bruce E. Schratz, M.D.
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JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Things To Come
April 4-5
Clinical Pulmonary Update. Washington Univer-
sity Medical Center, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 10-12
Refresher Course & Update in General Surgery.
The Ritz-Carlton Hotel, St. Louis, Missouri. Sponsored
by the Office of Continuing Medical Education, Wash-
ington University School of Medicine. For more infor-
mation, call 1-800-325-9862.
April 11-13
Infectious Disease 97: A Comprehensive Review
for the Practicing Physician. Renaissance Washing-
ton D.C. Hotel - Downtown. Sponsored by the Center
for Bio-Medical Communication, Inc. For more infor-
mation, call (201) 385-8080.
April 17-20
National Kidney Foundation 6th Annual Spring
Clinical Nephrology Meetings Consultative Nephrol-
ogy Program. Wyndham Anatole Hotel, Dallas, Texas.
For more information, call 1-800-622-9010.
April 24-26
14th Annual Dermatology Update and All That
Jazz. Hyatt Regency Hotel, New Orleans, Louisiana.
Sponsored by Tulane University Medical Center De-
partment of Dermatology and the Center for Continu-
ing Education. For more information, call (504) 588-
5466 or 1-800-588-5300.
April 25-27
1997 Pediatric Update for the Primary Care Phy-
sician. The Westin Canal Place, New Orleans, Louisi-
ana. Co-sponsored by the Alton Ochsner Medical Foun-
dation and Tulane University School of Medicine. For
more information, call (504) 842-3702 or 1-800-778-9353.
May 1-3
Arkansas Medical Society Annual Session - Scal-
ing New Heights. Arlington Hotel, Hot Springs. For
more information, call 1-800-542-1058 or 501-224-8967.
May 8-10
Ambulatory Surgery '97: Sharing Our Experiences
FASA 23rd Annual Meeting. Marriott Copley Place
Hotel, Boston, MA. For more information, call (703)
836-8808.
May 21-24
National Rural Health Association 20th Annual
National Conference: Caring for the country... Partnerships
for Health. Westin Hotel, Seattle, Washington. For more
information, write to NRHA, One West Armour Bou-
levard, Suite 301, Kansas City, Missouri, 64111.
July 7-10
17th Annual Current Concepts in Primary Care
Cardiology. Hyatt Regency Lake Tahoe, Incline Vil-
lage, Nevada. Sponsored by UC Davis School of Medi-
cine and Medical Center, Division of Cardiovascular
Medicine and Office of Continuing Medical Education.
For more information, call (916) 734-5390.
September 5-7
4th Annual Current Topics in Cardiothoracic An-
esthesia. Washington University Medical Center, St.
Louis, Missouri. Sponsored by the Office of Continu-
ing Medical Education, Washington University School
of Medicine. For more information, call 1-800-325-9862.
September 18-20
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
October 26-30
1997 State-of-the-Art Conference: Occupational
and Environmental Medicine. Nashville, Tennessee.
Sponsored by the American College of Occupational
and Environmental Medicine. For more information,
call (847) 228-6850, ext. 152.
Volume 93, Number 10 - March 1997
503
Keeping Up
April 3-5
Symposium on Critical Care and Emergency Medicine. Time:
Registration at 7:00 a.m. Location: Hot Springs Hilton, Hot Springs.
Accrediting organization sponsoring program: jointly sponsored by
the University of Tennessee at Memphis College of Medicine and
the University of Arkansas for Medical Sciences. Hours of Category
1 credit offered: 1 1.25. For more information, call 501-661-7962.
April 19
ACLS 1 Day Recert Course. Time: 7:30 a.m. to 5 p.m. Location:
St. Vincent Infirmary Medical Center, Center for Health Education.
Sponsor: St. Vincent Infirmary Medical Center. Hours of Category
1 credit offered: 8. For more information, call 501-660-3678.
April 19
Primary Care Cardiology Update '97. Time: 8 a.m. to 2 p.m.. Lo-
cation: Clarion Inn, Fayetteville. Sponsor: Washington Regional
Medical Center. Hours of Category 1 credit offered: 6. Fee: none.
For more information, call 501-442-1823 or 1-800-422-0322.
April 26
Contemporary Cardiology Update. Time: 8 a.m. to 1 p.m.. Loca-
tion: St. Vincent Infirmary Medical Center, Center for Health Edu-
cation. Sponsor: St. Vincent Infirmary Medical Center. Hours of
Category 1 credit offered: 4.50. Fee: none. For more information,
call 501-660-3594.
May 1-2
ACLS 2 Day Provider Course. Time: 7:30 a.m. - 5 p.m.. Location:
St. Vincent Infirmary Medical Center, Center for Health Education.
Sponsor: St. Vincent Infirmary Medical Center. Hours of Category
1 credit offered: 16. For more information, call 501-660-3678.
May 30 - June 1
19th Annual Family Practice Intensive Review. Location: UAMS,
Education II Building, Little Rock. Program Presenters: Department
of Family and Community Medicine. Accrediting organization spon-
soring program: UAMS College of Medicine. Hours of Category 1
eredit offered: Up to 20 hours of CME credit. Fee: TBA. For more
information, call 501-661-7962.
October 3-5
Primary Care Update (Management of Top 20 Ambulatory Di-
agnoses). Location: Gaston's Lodge on the White River. Sponsor:
Washington Regional Medical Center. For more information, call
501-442-1823 or 1-800-422-0322.
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor co7itinuing medical education for physicians. The
organizations named designate these contmuing medical education activities for the credit hours specified in Category 1 of the Physician's
Recogftition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/ General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
FAYETTEVILLE-WASHINGTON REGIONAL MEDICAL CENTER
Cardiology Conference, 3rd Wednesday of every month, 7:30 - 8:30 a.m., WRMC, Baker Conference Center, no fee, breakfast provided
Chest Conference, 1st Wednesday of every month, 12:15 - 1:15 p.m., WRMC, Baker Conference Center, no fee, lunch provided
Primary Care Conferences, every Monday, 12:15 - 1:15 p.m., WRMC, Baker Conference Center, no fee, lunch provided
Tumor Conference, every Thursday, 7:30 - 8:30 a.m., WRMC, Baker Conference Center, no fee, breakfast provided
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Breast Conference, 3rd Thursday, 7:00 a.m., J.A. Gilbreath Conference Center, Room #20
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Disorders Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
504
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The University of Arkansas College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor the
following continuing medical education activities for physicians. The Office of Continuing Medical Education designates that these activities
meet the criteria for credit hours in category 1 toward the AMA Physician's Recognition Award. Each physician should claim only those
hours of credit that he/she actually spent in the educational activity.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Anesthesia Grand RoundsIM&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTl Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Fetal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
Volume 93, Number 10 - March 1997
505
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology /Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Senes, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/ Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital CME Conference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
506
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Internal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
THE ARMY RESERVE OFFERS UNIQUE AND
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variety of challenges and rewards. You will also have a unique
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Volume 93, Number 10 - March 1997
507
Advertisers Index
Advertising Agencies in italics
AMS Benefits 475
Arkansas Children's Hospital inside back
Autoflex Leasing inside front
Freemyer Collection System 478
Med Plus Leasing 478
McNabb, Kelley & Barre
Medical Practice Consultants, Inc 488
Riverside Motors, Inc 487
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory back cover
Strategic Marketing
State Volunteer Mutual Insurance Company 470
The Maryland Group
Southwest Capital Management 486
Marion Kahn Communications, Inc.
U.S. Air Force 469
BJK&E Specialized Advertising
U.S. Army Reserve 507
Young & Rubicam, Inc.
Information for Authors
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on the condition that they are contributed solely to this
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The Journal of the Arkansas Medical Society reserves the
right to edit any material submitted. The publishers accept
no responsibility for opinions expressed by the contributors.
All manuscripts should be submitted to Tina G. Wade,
Managing Editor, Arkansas Medical Society, P.O. Box
55088, Little Rock, Arkansas 72215-5088. A transmittal
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For a reprint price list, contact Tina G. Wade, Managing
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less than 100 copies.
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UNIVERSITY ' OF MARYLAND, AT
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE PRESIDENT
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
David Wroten
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
Obstetrics/ Gynecology
Internal Medicine
Surgery
Family Practice
UAMS
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
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to make the final decision on all content and
advertisements.
Copyright 1997 by the Arkansas Medical Society.
Volume 93
Number 11
April 1997
CONTENTS
FEATURES
512
Medicine in the News
Health Care Access Foundation Update
Influenza Immunization and Comeal Transplant Rejection
AMA Launches New Coalition for Tobacco-free Investments - Growing Number
of U.S. Funds Kick the Habit
ACR Continues Support of Mammography Screening for VJomen 40-49, Says
NIH Panel Misread Data
Disciplinary Action Bulletin - Arkansas State Board of Nursing
517
121st AMS Annual Session Schedule and Speakers
520
AMS Convention Highlights and AMS Alliance Schedule
522
AMS Annual Session Registration Form
523
524
Fifty Year Club * •
AMS House of Delegates
Register Today! |
527
AMS Nominating Committee Report
528
AMS Reference Committee Agendas
529
AMS Business Reports for Reference Committee #1
539
AMS Business Reports for Reference Committee #2
551
1997 MED-PAC Contributors
552
1996 MED-PAC Contributors
554
Memorials
DEPARTMENTS
516 AMS Newsmakers
555 Cardiology Commentary & Update
558 State Health Watch
560 Arkansas HIV/AIDS Report
565 Radiological Case of the Month
567 In Memoriam
567 Things to Come
569 Keeping Up
Cover photograph taken by Matt Bradley of Little Rock.
Medicine in the News
Health Care Access Foundation
As of March 1, 1997, the Arkansas Health Care
Access Foundation has provided free medical service
to 12,327 medically indigent persons, received 23,370
applications and enrolled 45,601 persons. This program
has 1,748 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
Influenza Immunization and Corneal
Transplant Rejection
The "flu season is upon us, and many of our pa-
tients have received or will receive immunizations
against influenza virus. Influenza vaccination has been
reported to prevent illness in 70% of healthy persons
under 65 years of age.’ Furthermore, the vaccine is
recommended for individuals at high risk for influ-
enza complications, including the nearly 60 million
elderly persons in the United States. Approximately
70 million doses of the attenuated virus vaccine were
available during the 1995-1996 influenza season.^ Last
year Nichol et aP reported the efficacy and health re-
lated benefits following influenza vaccine in healthy
working adults.
We wish to caution readers regarding a potential
complication of influenza vaccine. Several years ago
we reported the association of corneal transplant re-
jection and immunization occurring in five patients.''
Four of these patients developed corneal transplant
rejection within several weeks following influenza
immunization. Two of the four corneal transplant re-
jection episodes resolved following intensive corticos-
teroid therapy. Recently, Solomon and Frucht-Pery5
reported a patient who experienced a bilateral corneal
transplant rejection six weeks after influenza vaccina-
tion. The graft reactions were treated successfully with
oral and topical corticosteroids. Several months later
the patient again received an influenza vaccination,
but topical steroid therapy was increased during the
month following immunization. The corneal trans-
plants remained clear fourteen months after the bilat-
eral transplant rejection episode.
Clearly, the reported association between corneal
transplant rejection and influenza immunization is tem-
poral and presumptive. However, the occurrence of
this phenomenon may be more frequent than reported,
and we believe that primary care physicians, ophthal-
mologists, and patients alike need to be aware that
immunization may potentiate a threat to the health of
a corneal transplant. Patients with corneal transplants
512
should be treated with increased topical steroids both
before and after immunization.
Authors:
*Thomas L. Steinemann, M.D., Associate Professor, Cornea
and External Disease Services, Jones Eye Institute, Depart-
ment of Ophthalmology, UAMS.
*Bruce H. Koffler, M.D., Clinical Associate Professor, Uni-
versity of Kentucky, Department of Ophthalmology, Lex-
ington, Kentucky.
References:
1. Arden NH, Cox, NJ. Prevention and control of influenza:
recommendations of the Advisory Committee on Immuni-
zation Practices (ACIP). MMWR Morb Mortal Wkly Rep 1996;
45(RR5): 1-24.
2. Patriarca PA, Strikas RA. Influenza vaccine for healthy
adults? N Eng J Med 1995; 333:933-934.
3. Nichol KL, Lind A, Margolis KL et al. The effectiveness of
vaccination against influenza in healthy working adults. N
Eng J Med 1995; 333:889-893.
4. Steinemann TL, Koffler BH, Jennings CD. Corneal allograft
rejection following immunization. Am J Ophthalmol 1988;
106:575-578.
5. Solomon A, Frucht-Pery J. Bilateral simultaneous corneal
graft rejection after influenza vaccination. Am J Ophthalmol
1996; 121 :708-709.
AM A Launches New Coalition for Tobacco-
free Investments - Growing number of U.S.
funds kick the habit
American investors are kicking the habit, accord-
ing to the American Medical Association (AMA), which
on March 4, 1997, launched a new coalition of
tobacco-free mutual funds that have pledged not to
invest in 17 identified tobacco stocks.
"The societal sea change against tobacco has the
AMA's Coalition growing by the day," said Randolph
Smoak, Jr., M.D., AMA secretary-treasurer. "Inves-
tors are refusing to allow their hard-earned money to
support an industry whose product causes suffering,
addiction and death."
The AMA's "Coalition for Tobacco-free Invest-
ments" is a group of 53 U.S. mutual funds that do not
hold tobacco investments and have pledged not to
purchase tobacco stocks and bonds in the future. Its
membership includes Stein Roe's Young Investor Fund,
which targets America's new generation of investors,
as well as institutional investors such as the American
Hospital Association Investment Program.
"Our clients see tobacco investments as a stark
contradiction to their mission in a world where much
of their time and resources are spent caring for patients
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
suffering from tobacco-related diseases," said Tim
Solberg of the American Hospital Association's Invest-
ment Program.
In April 1996, the AMA called tobacco a "ruinous
and enslaving product that has brought misery, dis-
ease, anguish and death," and urged investors to di-
vest of tobacco stocks and 1,474 mutual funds identi-
fied as invested in the manufacture or processing of
tobacco products or tobacco companies. Since then,
the AMA has invited all mutual funds traded in the
U.S. to make the tobacco-free pledge and join the
AMA's Coalition.
"Being part of the AMA's Coalition broadens our
reach to a special group of shareholders who are con-
cerned about health and are conscientious investors,"
said Dave Brady, vice president of Stein Roe's Young
Investor's Fund. "Being recognized by a prestigious
organization like the AMA can only help our fund."
Members of the Coalition are authorized to use
the "AMA Coalition for Tobacco-free Investments" logo
and will have their names published annually in the
AMA's national publications and on the Association's
World Wide Web site.
"We see this as a service to our members, public
health advocates, medical institutions, and others who
are interested in the health and welfare of our chil-
dren," said Smoak. "We intend to continue to build
this list of tobacco-free funds so that investors will
eventually have hundreds of options."
The AMA list of tobacco stocks is derived from a
universe of tobacco equities tracked by the Investor
Responsibility Research Group (IRRC), a non-for-profit,
independent research firm, based in Washington, D.C.
The firm identified 17 tobacco manufacturers traded
in the U.S. exchanges: American Brands; B.A.T In-
dustries PTC; Brooke Group Ltd.; Garibbean Gigar
Gorp.; Consolidated Cigar; Culbro Corp.; DiMon, Inc.;
Empresas La Moderna; Loews; Mafco Consolidated
Group, Inc.; Philip Morris Gos., Inc.; RJR Nabisco
Holding Corp.; Sara Lee Corp.; Schweitzer-Maudit
Inti.; Standard Commercial Corp.; UST, Inc.; Univer-
sal Corp.
AMA's call for divestment of tobacco stocks and
mutual funds follows its decision in 1986 to divest to-
bacco stocks in the AMA's portfolio. Other public
health organizations that divested during the 1980's
included the American Heart Association, American
Lung Association and the American Cancer Society.
Since the AMA's latest call in April, more atten-
tion has focused on tobacco investments. The Massa-
chusetts House of Representatives approved divest-
ment legislation for the state employees' $17 billion
Public Retirement Investment Trust. Also, the $55 bil-
lion New York State Teachers' Retirement System sold
nearly $100 million of tobacco stocks to "underweight"
its financial exposure. And currently, other pension
funds like the $45 billion New York City Employees'
Retirement System are reviewing their tobacco stock
holdings now.
"We appear to be entering a third phase of to-
bacco divestment activity," said Doug Cogan of the
IRRC. "Public health associations like the AMA were
among the first to shun tobacco investments in the
1980s, followed by some large universities with medi-
cal schools in the early 1990s. Now that attention is
turning to mutual funds and pension fund investments
in tobacco, the equity capital at stake is greater than
ever."
The AMA does not endorse any investment ve-
hicle and does not guarantee any rate of return. - In-
formation provided by the AMA Fed-Net dated March 4,
1997.
ACR Continues Support of Mammography
Screening For Women 40-49, Says NIH Panel
Misread Data
The American College of Radiology (ACR) recently
reaffirmed its strong support for mammography screen-
ing for women in their 40s and said that a National
Institutes of Heath Panel failed to recognize and incor-
porate into its report important new follow-up data
from clinical trials that confirms the benefits of this test.
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Volume 93, Number 11 - April 1997
513
The College also said that the panel's decision not
to recommend screening mammography for women
40-49 was regrettable and not in the best interest of
American women in this age group.
Two independent studies from Sweden, one from
Gothenburg the other from Malmo, reported at the
meeting a statistically significant decrease in the breast
cancer death rate of 44% and 36% respectively for
women who began screening in their 40s.
The NIH Consensus Panel has stated that after
considering information from numerous studies it did
not find sufficient evidence to warrant screening mam-
mography for women aged 40-49.
ACR, on the other hand, pointed out that not only
did randomized trials around the world show a statis-
tically significant benefit, but numerous other studies
involving hundreds of thousands of women have
shown that with mammographic screening the breast
cancer death rate can be reduced substantially.
For the past two years, the National Cancer Insti-
tute (NCI) has reported that the mortality rate from
breast cancer has dropped for all age groups, includ-
ing those 40-49. This is the first time in 40 years there
has been a decline and NCI has concluded that this
decrease is due, in part, to breast cancer detection with
screening mammography. It is ironic that the NCI
decision came so soon after such recent good news
concerning the fight against breast cancer in the United
States and around the world.
Not only is the evidence compelling that this age
group should be screened, but a growing number of
studies clearly indicate the screening interval for
women 40-49 should be shortened from the present
recommendation of every 1-2 years to every year. Since
NCI has clearly indicated it will not be involved with
guidelines, in the very near future, numerous national
health care groups plan to meet to address the issue
of yearly mammography screening in this age group
and to give more guidance to women in their 40s.
Since NCI withdrew its support for screening
women in their 40s more than three years ago, ACR
and more than 20 other national medical organizations
and women's groups have continued to support screen-
ing this age group. More than 30,000 women in the
United States aged 40-49 are diagnosed with breast
cancer each year and to discourage women in their
40s from having life-saving mammography is a tragic
mistake. - Information provided by the American College of
Radiology via news release.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
514
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board office should be contacted. There-
fore, the Board routinely suggests this list be shared
with the appropriate supervisory personnel and re-
cruiters in your organization. At the completion of the
disciplinary period, the nurse applies for reinstatement.
Reinstatement is contingent upon meeting the condi-
tions set forth by the Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY: February 14, 1997
*Nancy Susan Isch, RN 44280 (Conway) Reinstated
followed by 1 year suspension
Douglas Hall, LPN 30049 West Memphis (Brookland,
AR) Suspension - 5 years; Civil penalty - $1,500.
*Tracy Lynn Whitlock Mason, LPN 30698 McCrory (Bald
Knob, AR) Suspension - 2 years; Civil penalty - $2,500.
*Leigh Ann Benton, RN 39923 (Pine Bluff) License re-
newed followed 3 years suspension; Civil penalty - $2,500.
*Sharon Kay Howard Dozier, LPN 5732 (Hampton,
New Hampshire) Consent agreement; probation - 6
months; Civil penalty - $500.
*Sally Jean Robbins, RN 53509 (Perryville) Allowed to
endorse; consent agreement; probation - 3 years.
VOLUNTARY SURRENDER:
■^Christopher Allen Sullivan, LPN 31472 (Cabot) 1/13/97
■^Jerry Lee Keister, LPTN 537 (Jacksonville) 2/4/97
■^Melissa Ann Hamilton, RN 51996 (Pine Bluff) 2/5/97
ALERT:
If you have employed the following nurses or have
any knowledge of their whereabouts, please notify the
Board of Nursing at (501) 686-2700.
■^Judy Fox, LPN 17755
■^Paula Johnson, LPN 12394
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JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Medicare Post Pay Review Audits
Effective January 1 , 1997, the federal government will step up their efforts to identify
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AMS Newsmakers
Dr. Omar Atiq, a Pine Bluff oncologist/hematolo-
gist, recently returned from his native land of
Peshawar, Pakistan, where he is assisting with the es-
tablishment of an adult leukemia clinic. Dr. Atiq is
serving as a United Nations consultant as part of the
U.N.'s Transfer of Technology to Developing Nations.
Dr. Charles Horton, a family practitioner of
Berryville, was recently appointed to serve on the Ar-
kansas Managed Care District II Consortium Board for
Ryan White Funding. This group is one of five in Ar-
kansas formed to handle a variety of HIV/AIDS and
support services needed throughout the state. In ad-
dition, the Ozarks AIDS Resources and Services (OARS)
group awarded Dr. Horton with a certificate of appre-
ciation for donating thousands of hours to the OARS
HIV/AIDS Clinic.
Dr. Robert Miller, a family practitioner of Hel-
ena, was recently elected president of the Arkansas
Department of Health's board of directors for 1997.
He will also serve on the board's executive and rural
health committees.
Dr. Kerry Pennington, a family practitioner of
Warren, was recently named to the board of trustees
at Central Baptist College to serve a second five-year term.
Dr. Trent Pierce, a family practitioner of West
Memphis, was recently appointed by Gov. Mike
Huckabee to the Arkansas State Medical Board. He
will serve through December 31, 2004.
Dr. F. Hampton Roy, of Little Rock, was recently
elected President of the American College of Eye Surgeons.
Dr. Joe Shelton, a general practitioner, was re-
cently honored with a reception at the Little River
County Courthouse and a plaque from Little River
Memorial Hospital for over 50 years of service and
dedication to the citizens and medical community. He
retired at the end of 1996.
Send your accomplishments and photo for
consideration in AMS Newsmakers to: Arkansas
Medical Society, Journal Editor, PO Box 55088,
Little Rock, AR 72215-5088
Freemyer Collection System, Inc.
1-800-694-9288
Collection Services
Electronic Claims
Remittance Posting
Physician Billing
Established 1941
Blytheville *Conway * Helena * Jonesboro * Little Rock * Paragould *West Memphis
516
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
ARKANSAS AllEDICAL SOCIETY
CONVENTION REGISTRATION
SCALING
NEW
1997 ANNUAL CONVENTION
ARLINGTON HOTEL HOT SPRINGS, ARKANSAS
MAYI-3,1997
\2F ms ANNUAL SESSION
CONVENTION SCHEDULE
SCALING
ARLIMGTON HOTEL HOT SPRINGS, ARKANSAS
TARGET AUDIENCE
This meeting is designed primarily for Arkansas physicians
concerned with health care issues that affect the practice of
medicine. Clinic managers, medical students, residents
and other health care professionals will also benefit from
this program.
PROGRAM OBJECTIVES
THURSDAY, MAY 1, 1997
9:00 a.m.
11:30 a.m.
Dr. Harold “Bud” Purdy Memorial
Golf Tournament
Hot Springs Country Club
Sponsored by Schering Corporation
Fifty Year Club Luncheon
12:30 p.m.
Registration Opens
1:00 p.m. Seminar for Young Physicians
“Getting Started in Medical Practice”
Art Votek
Conomikes Associates
Los Angeles, California
Art Votek is a Senior Staff Associate for
Conomikes Associates. He will lead this
informative seminar which is designed for
residents and other physicians who may be
joining a group, HMO or going solo. The
seminar will help minimize costly mistakes and
include such issues as buy-sell; salary and
income distribution, employment agreements,
revenue and managed care.
2:00 p.m. Council Meeting
3:30 p.m. Welcome Reception
Exhibits Open
Sponsored by Boatmen 's National
Bank of Arkansas
* Summarize the activities of the AMA and learn how changes
on a national level will affect the practice of medicine.
*Leam to minimize costly mistakes when joining a group or
entering solo practice, including how managed care affects
revenue and patient management.
* Examine the physician accreditation programs from a state
and national perspective.
*Discuss the values physicians want to preserve and a
positive plan for preserving those values.
* Identify changes made in state law from the recent Arkansas
General Assembly which will affect patients and the practice
of medicine.
*Network and exchange ideas with colleagues.
CME HOURS
St. Joseph’s Regional Health Center is accredited by the
Arkansas Medical Society to sponsor continuing medical
education for physicians. St. Joseph’s Regional Health
Center designates this continuing medical education
activity for 7.5 credit hours in Category I of the Physician’s
Recognition Award of the American Medical Association.
5:00 p.m. House of Delegates
Keynote Speaker
Randolph D. Smoak Jr., MD
Secretary-Treasurer
American Medical Association
Orangeburg, South Carolina
Dr. Randolph D. Smoak Jr. is a general
surgeon from Orangeburg, South Carolina,
and he was elected Secretary-Treasurer of
the American Medical Association (AMA) in
December 1995. He has been reelected to a
second term on the AMA Board of Trustees
in June 1995. Since 1994, Dr. Smoak has
served on the Board’s Executive Committee
and as chair of its Finance Committee.
6:00 p.m. Opening Night Reception
Physicians, spouses, guests, exhibitors and
sponsors are invited.
Co-sponsored by Blue Cross Blue
Shield of Arkansas and Southern
Medical Association
Randolph D.
Smoak Jr., MD
Orangeburg, SC
FRIDAY, MAY 2, 1997
7:30a.m. Council Meeting
8:30 a.m. Continental Breakfast
Exhibits Open
Sponsored by First Commercial Bank
9:30 a.m. Reference Committee Meeting I & II
CONVENTION SCHEDULE
1
10:30 a.m.
Michael N.
Moody. MD
Salem, AR
First Feature Session
“Physician Accreditation in the New
Managed Care Environment”
Panel Discussion
Michael N. Moody, MD
Arkansas Foundation for Medical Care
Salem, Arkansas
Randolph D. Smoak Jr., MD
AMA Commissioner
Joint Commission on Accreditation
of Healthcare Organizations
Orangeburg, South Carolina
Carol Zylman
Centralized Credentials Verification
Service Committee
Little Rock, Arkansas
Arkansas State Medical Board
Educational grant given by
The St. Paul Companies
Dr. Michael N. Moody is a board-certified
family physician practicing at the Salem Family
Clinic and is currently serving as Secretary of
the Arkansas Medical Society. As medical
director of the Arkansas Foundation for
Medical Care, he is involved with the Arkansas
Medicaid Primary Care Case Management
program. He is currently serving on the
Arkansas Board of Health.
Dr. Randolph D. Smoak Jr. has served in
virtually every leadership position in the South
Carolina Medical Association, including
President. He is a fellow of the American
College of Surgeons and is currently serving
as Governor from South Carolina to the
American College of Surgeons. Dr. Smoak is a
diplomate of the American Board of Surgery.
12:00 p.m.
The Honorable
Vic Snyder, MD
Little Rock, AR
Shuffield Lecture/Luncheon
The Honorable Vic Snyder, MD
United States Congressman, Second District
Little Rock, Arkansas
An educational grant given by
Freemyer Collection System
Congressman Vic Snyder, MD was elected from
the Second District to the United States Congress
in November 1995. He is on the House Veterans ’
Affairs Committee and the National Security
Committee. Congressman Snyder completed
his residency in family practice at the University
of Arkansas for Medical Sciences and received
his Medical Degree from the University of
Oregon. He has a Law Degree from the Uni-
versity of Arkansas at Little Rock School of Law.
Robert Lyman
Potter, MD. PhD
Kansas City, MO
Dr. Robert Lyman Potter is from the Bioethics
Development Group, a national division of the
Bioethics Center. He has a private practice in
internal medicine and is medical director for four
nursing homes. Dr. Potter divides his time
between practicing, teaching and ethics lecturing.
Dr. Potter will present a program outlining
the values which physicians want to preserve
and then a positive plan for using bioethics as
the mechanism for preserving those values.
This program is a constructive response to
ethical issues in managed care.
6:00 p.m.
Hospitality Hour
Sponsored by Janssen Pharmaceuticals
7:00 p.m.
9:00 p.m.
Andy Childs
Memphis, TN
Inaugural Banquet
President's Reception «& Dance
Sponsored by National Park Medical Center
Banquet Entertainment: Andy Childs
Childs has- served as musical director and
opening act for stars like Chubby Checker,
Chuck Berry, Jerry Lee Lewis, Carl Perkins,
Fabian, Frankie Avalon and many others. In
1993, Childs signed with RCA Records in
Nashville. Childs has toured recently with Clint
Black, Trisha Yearwood and Tanya Tucker.
SATURDAY, MAY 3, 1997
7:30 a.m.
Council Meeting (tentative)
8:00 a.m.
Early Morning Refreshments
Sponsored by American Investors Life
Insurance Company
8:45 a.m.
Z. Lynn Zeno
Little Rock, AR
Third Feature Session
“Legislative Report from the
81st General Assembly”
Z. Lynn Zeno
Director of Governmental Affairs
Arkansas Medical Society
Little Rock, Arkansas
Z Lynn Zeno, Director of Governmental Affairs
for the Arkansas Medical Society, will update the
AMS membership on the activities of the 81st
General Assembly. Mr. Zeno will discuss
insurance regulations, Medicaid, tort reform and
other medical-related bills which were discussed
and acted upon by the state legislature.
1:30 p.m. Afternoon Break
Exhibits Open
Sponsored by State Volunteer Mutual
Insurance Company
3:00 p.m. Second Feature Session
“Ethical Issues in Managed Care: A
Practical Plan of Action”
Robert Lyman Potter, MD, PhD
Bioethics Development Group
Kansas City, Missouri
10:30 a.m. House of Delegates
12:30 p.m Specialty Meetings
Arkansas Academy of Family Physicians
Arkansas Chapter, American Academy
of Pediatrics
Arkansas Chapter, American College of
Emergency Physicians
Arkansas Pathology Society
Arkansas Urologic Society
CONVENTION HIGHLIGHTS
DR. HAROLD "BUD" PURDY MEMORIAL
GOLF TOURNAMENT
Tee off the convention by bringing your clubs to
the Hot Springs Country Club on Thursday,
May 1 at 9:00 a.m. The tournament will be a 4
person scramble and USGA rules will prevail.
The golf tournament is sponsored by
Schering Corporation. aEi
WELCOME RECEPTION
Visit with your colleagues, spouses and exhibitors during
the first exhibit time - just prior to the First House of
Delegates and keynote address by Dr. Randolph D. Smoak
Jr. The reception is sponsored by Boatmen's National
Bank of Arkansas.
OPENING NIGHT RECEPTION
Enjoy good food, good fun and renew old friendships at
the Opening Night Reception. Co-sponsored by Blue Cross
Blue Shield of Arkansas and Southern Medical Association.
CONTINENTAL BREAKFAST
Enjoy breakfast while you visit with the 1997 exhibitors at
their booths. Be sure to stop by every booth to qualify for
the Grand Prize Drawing. The breakfast is sponsored by
First Commercial Bank.
AFTERNOON BREAK
Take a break from the meetings to relax and talk with
exhibitors. The Grand Prize will be drawn during the break
... so make plans to be there. Sponsored by State Volunteer
Mutual Insurance Company.
HOSPITALITY HOUR
Prior to the Inaugural Banquet and President’s Reception
& Dance, visit with friends and family at the AMS
Hospitality Hour. The Hospitality Hour is sponsored by
Janssen Pharmaceuticals.
INAUGURAL BANQUET
Join us for a fabulous dinner at the Inaugural Banquet. Dr.
Charles Logan of Little Rock will be installed as the 1997-98
AMS President.
PRESIDENT'S RECEPTION & DANCE
The Inaugural Banquet will be followed by the President’s
Reception & Dance. Entertainment will be by Andy Childs
from Memphis, Tennessee. The President’s Reception &
Dance is sponsored by National Park Medical Center.
EARLY MORNING REFRESHMENTS
Stop by for breakfast on Saturday morning. Early
Morning Refreshments are sponsored by American
Investors Life Insurance Company.
OTHER ACTIVITIES
THE PRESIDENTS' CLUB
The Presidents’ Club will meet Wednesday, April 30 at
6:30 p.m. at the Arlington Hotel. The group consists of
presidents, president-elects and past presidents of the
Arkansas Medical Society, county and specialty societies.
FIFTY YEAR CLUB LUNCHEON
The Society will host a luncheon for The Fifty Year Club
at 1 1 :30 a.m. on Thursday, May 1 at the Arlington Hotel.
SPECIALTY MEETINGS
Arkansas Academy of Family Physicians will meet at
12:30 p.m. at the Arlington Hotel on Saturday, May 3.
Lunch reservations are necessary.
Arkansas Chapter, American Academy of Pediatrics
will meet at 12:30 p.m. at the Arlington Hotel on
Saturday, May 3.
Arkansas Chapter, American College of Emergency
Physicians will meet at 12:30 p.m. at the Arlington
Hotel on Saturday, May 3.
Arkansas Pathology Society will meet at 12:30 p.m. at
the Arlington Hotel on Saturday, May 3.
Arkansas Urologic Society will meet at 12:30 p.m. at
the Arlington Hotel on Saturday, May 3.
AMS ALLIANCE CONVENTION SCHEDULE
THURSDAY,
MAY 1, 1997
2:00 p.m.
Pre-convention Board Meeting
3:30 p.m.
Welcome Reception
5:00 p.m.
AMS House of Delegates
6:00 p.m.
Opening Night Reception
FRIDAY, MAY 2, 1997
7:30a.m.
Past Presidents’ Breakfast
8:00 a.m.
Membership Roundtable Discussion
9:00 a.m.
Opening General Session
1 1:00 a.m.
Alliance Feature Session
12:00 p.m.
Shuffield Lecture & Luncheon
1:30 p.m.
Update from National
3:00 p.m.
Tennis Round Robin
5:00 p.m.
Walking Art Tour
6:00 p.m.
AMS Hospitality Hour
7:00 p.m.
AMS Inaugural Banquet
9:00 p.m.
AMS President’s Reception & Dance
SATURDAY, MAY 3, 1997
9:00 a.m. Second General Session/Update from SMAA
12:00 p.m. Installation & Awards Luncheon
2:00 p.m. Post-convention Board Meeting
li
IMPORTANT INFORMATION
MEETING REGISTRATION . . .
Return your meeting registration form by April 25, 1997, with a check (sorry, no credit cards) made payable to Arkansas
Medical Society or AMS:
Arkansas Medical Society
P.O. Box 55088
Little Rock, AR 72215-5088
Refunds prior to April 25, 1997 will be at the full amount. Refunds after April 25, 1997 will be charged a $10
processing fee which will be mailed after the convention.
NEED SPECIAL ASSISTANCE . . .
If you are a person with a disability or special needs, please let us know in advance so that we can arrange to make
your attendance as convenient and comfortable as possible. Please call the Society office at (501) 224-8967 or
1-800-542- 1 05 8 to make arrangements.
SPOUSES AND GUESTS . . .
Spouses and guests are invited to attend the AMS annual convention for a registration fee of $55. This
allows access to all sessions, exhibit center and social activities.
AMS ALLIANCE ACTIVITIES . . .
The AMS Alliance Annual Session is meeting in conjunction with the AMS Annual Session. Please consult the
registration form for the fee involved.
HOTEL RESERVATIONS . . .
Hotel reservations can be made directly with the Arlington Hotel. Hotel deadline is April 9, 1997. After that date, AMS
convention rates cannot be guaranteed.
$75 Single/$75 Double
Arlington Hotel
PO Box 5652
Hot Springs, Arkansas 71902
(501) 623-7771
MEETING ATTIRE . . .
General sessions, education programs and other daytime activities - business attire, but dress comfortably. Dress up for
the Inaugural Banquet and President’s Reception & Dance.
SCALIMG NEW HEIGHTS
1997 CONVENTION REGISTRATION FORM
Arkansas Medical Society
P.O. Box 55088, Little Rock, AR 722 1 5-5088
(50 1 ) 224-8967 1 -800-542- 1 058 (WATS)
Complete the registration form following steps 1 through 6 and return by mail with check to the AMS office. Pick up tickets and badge
at the AMS Registration Desk on the Mezzanine Level of the Arlington Hotel.
o
(Please Print) Dr.
Spouse
This is my first convention
Guest
Address
City
State
Zip
Phone
©
For appropriate meal count, please indicate the number of physicians, spouses and guests attending:
#Attending Shuffield Luncheon #Attending AMS Inaugural Banquet
Registration Fees
Pre-Paid
On-Site
AMS Registration Includes:
Member
$90
$125
♦Entrance into the Exhibit Center and
Past President
$70
$105
Exhibit Center Breaks
♦Resident/Spouse
$5
$10
♦CME Hours
♦Medical Student/Spouse
$5
$10
♦Shuffield Luncheon
Spouse
$55
$70
♦ Social Events such as Opening Night
Guest
$55
$70
Reception, Inaugural Banquet and
President’s Reception & Dance
Non-member
$110
$145
Note: Spouse fee does not include
* Resident/student/spouse fee does not include Inaugural Banquet
Alliance Luncheon.
Ticket, but reservations can be made through the Society office.
(£) SEMINAR FOR YOUNG PHYSICIANS
Member ’ $10 $15
Non-Member $20 $25
Seminar for Young Physicians Includes:
* Workshop materials & CME hours
♦Thursday’s Exhibits
Q PR- HAROLD "BUD" PURDY MEMORIAL GOLF TOURNAMENT
Per person
$60
Please list handicap:
(7) ALLIANCE MEETING REGISTRATION FEE
Pre-Paid On-Site
AMSA Member $25 $30
Tennis Round Robin $5 $5
AMS Alliance Registration Includes:
*AMSA Meeting & Activities
♦Installation Luncheon
Didyou add the appropriate amounts to include member,
spouse, guest and alliance activities?
TOTAL AMOUNT ENCLOSED
Fifty Year Club Luncheon
The Fifty Year Club is composed of physicians who have held a license to practice medicine for fifty years.
The Society will host a luncheon for members of the Fifty Year Club at 11:30 a. m., Thursday, May 1, 1997, at the
Arlington Hotel in Hot Springs. Physicians eligible for the Fifty Year Club this year are:
John C. Baber, Jr., M.D., Little Rock
David S. Bachman, M.D., Dardanelle
H. A. Bailey, Jr., M.D., Little Rock
David L. Gibbons, M.D., Ozark
A. Meryl Grasse, M.D., Calico Rock
A. Vale Harrison, M.D., Little Rock
Frank M. James, M.D., Gage, Oklahoma
Kathleen C. Jones, M.D., Little Rock
Ralph F. Joseph, M.D., Walnut Ridge
J. F. Kelsey, M.D., Fort Smith
John W. Lane, M.D., Little Rock
Willie J. Lee, M.D., Hot Springs
Frank M. Lockwood, M.D., Fort Smith
James D. Mashburn, M.D., Fayetteville
William R. Meredith, M.D., Pine Bluff
J. Warren Murry, M.D., Fayetteville
Marvin C. Rhode, M.D., Pine Bluff
Boyd M. Saviers, M.D., Fort Smith
Jack A. Wood, M.D., Fayetteville
CALL TODAY
Ask for Craig to get your
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Carp oration
Volume 93, Number 11 - April 1997
523
1997 House of Delegates
The opening session of the House of Delegates of the Arkansas Medical Society will begin at 5:00 p.m. on
Thursday, May 1. Speaker of the House Anna Redman, M.D., will preside. All items of business to be consid-
ered by the House must either be printed in the convention issue of The Journal or submitted to the headquarters
office in writing twenty days prior to the meeting. Any new business proposed during the session of the House
of Delegates must have a two-thirds vote of attending delegates for introduction.
Items of business will be referred by the Speaker of the House of Delegates to one of two reference commit-
tees. Open hearings on those items of business will be held by the reference committees on Friday, May 2 at 9:30
a.m. All members of the Society are welcome to attend the meetings of the reference committees and to express
views on the various reports, resolutions, etc.
The following will be seated at the House of Delegates meeting during the 1997 Annual Session:
Officers
Anna Redman, Pine Bluff, Speaker, (ex-officio)
Kevin Beavers, Russellville, Vice Speaker,
(ex-officio)
John Crenshaw, Pine Bluff, President (ex-officio)
Charles Logan, Little Rock, President-elect
(ex-officio)
James Crider, Harrison, Vice President
(ex-officio)
Mike Moody, Salem, Secretary (ex-officio)
Lloyd Langston, Pine Bluff, Treasurer (ex-officio)
Councilors
District 1:
Joe Stallings, Jonesboro
Dwight Williams, Paragould
District 2:
Lloyd Bess, Batesville
Daniel Davidson, Searcy
District 3:
Hoy B. Speer, Jr., Stuttgart
P. Vasudevan, Helena
District 4:
John O. Lytle, Pine Bluff
Harold Wilson, Monticello
District 5:
Wayne Elliott, El Dorado
Ered Murphy, Magnolia
District 6:
George Einley, Hope
Michael Young, Prescott
District 7:
Robert McCrary, Hot Springs
Brenda Powell, Hot Springs
District 8:
David Barclay, Little Rock
Joseph Beck, Little Rock
Paul Cornell, Little Rock
Anthony Johnson, Little Rock
William Jones, Little Rock
Jerry Mann, Little Rock
J. Mayne Parker, Little Rock
Bruce Schratz, NLR
Samuel Welch, Little Rock
John L. Wilson, Little Rock
District 9: Carlton Chambers, Harrison
Anthony Hui, Fayetteville
William McGowan, Springdale
District 10: Gerald Stolz, Russellville
John Swicegood, Fort Smith
Paul Wills, Fort Smith
Past Presidents (ex-officio)
A. E. Andrews, Jr., Texarkana
C. Stanley Applegate, Jr., Springdale
Glen F. Baker, Little Rock
John P. Burge, Lake Village
Asa A. Crow, Paragould
C. Randolph Ellis, Malvern
Ross E. Fowler, Harrison
Charles R. Henry, Sr., Little Rock
Morriss M. Henry, Fayetteville
John M. Hestir, DeWitt
William N. Jones, Little Rock
W. Ray Jouett, Little Rock
Albert S. Koenig, Jr., Fort Smith
James M. Kolb, Jr., Russellville
Kemal E. Kutait, Fort Smith
J. Larry Lawson, Paragould
Ken Lilly, Fort Smith
C. C. Long, Fort Smith (Honorary)
Joseph A. Norton, Little Rock
Ben N. Saltzman, Mountain Home
Purcell Smith, Jr., Little Rock
H. W. Thomas, Dermott
T. E. Townsend, Pine Bluff
George Warren, Little Rock
James R. Weber, Jacksonville
Charles F. Wilkins, Jr., Russellville
John P. Wood, Mena
George F. Wynne, Warren
Ex-officio members shall have the power of voting on all subjects except the election of officers.
524
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Delegates for 1997 as submitted by county:
County
Delegate
Alternate
Arkansas (1)
Ashley (1)
Baxter (2)
Benton (4)
Boone (2)
Sue Chambers
Delegate
Carl Chambers
Bradley (1)
Tom Langston
Joe Wharton
Kerry Pennington
Carroll (1)
Chicot (1)
Clark (1)
Noland Hagood
Mark Jansen
Cleburne (1)
Columbia (1)
John Alexander, Jr.
Thomas Pullig
Conway (1)
Craighead/
Poinsett (7)
Terence Braden
Crawford (1)
Timothy Dow
Dennis Parten
Joe Stallings
Henry Stroope
R. Wendell Ross
Crittenden (2)
G. Edward Bryant
Trent Pierce
Cross (1)
Scott Ferguson
Robert Hayes
Willard Burke
Dallas (1)
John Delamore
Desha (1)
Drew (1)
Faulkner (2)
Randal Bowlin
John D. Smith
Ben Dodge
Phillip Stone
Franklin (1)
Garland (7)
Grant (1)
Greene/Clay (1)
Dwight Williams
Darrell Bonner
Hempstead (1)
Hot Spring (1)
Howard/Pike (1)
Independence (2)
John R. Baker
Jeff Angel
William Waldrip
Richard Van Grouw
Jackson (1)
Mufiz Chauhan
Roger Green
Jefferson (5)
Simmie Armstrong
Johnson (1)
Lafayette (1)
Jacquelyn Frigon
David Jacks
George Roberson
Jerrye Woods
Brad Harbin
Lawrence (1)
Robert Quevillon
Sebastian Spades
Lee (1)
Little River (1)
Logan (1)
John R. Williams
James Harbison
Lonoke (1)
Leslie Anderson
Medical Student (1)
Miller (3)
John Ford
F. E. Joyce
Joseph Robbins
Herbert Wren
Mississippi (1)
Joe Jones
Richard Hester
Monroe (1)
Nevada (1)
Ouachita (1)
William Dedman
Milton Brunson
Phillips (1)
L. J. Pat Bell, Sr.
Marion McDaniel
Polk (1)
Thomas Tinnesz
David Fried
Pope (3)
Stanley Bradley
Pulaski (39)
Rudolph Massey
David Murphy
William Ackerman
James Adametz
D. B. Allen
Dana Abraham
Pulaski (cont.)
Ray Biondo
Laurie Barber
Brad Baltz
Joe Buford
Bob Cogburn
Jeff Carfagno
Michael Cope
Roger Clark
David Coussens
Byron Curtner
Philip Deer, 111
David Dean
Shirley DesLauriers
Gilbert Dean
Thomas Eans
Gregory Dwyer
Jim English
Sidney Eudy
Thomas Frazier
Jay Flaming
Fred Henker
Eric Eraser
Reid Henry
David Gilliam
Steve Hodges
A. T. Gillespie
Jim Ingram
Michael Glidden
Thomas Jansen
Lawson Glover
Carl Johnson
James Hagler
Gail Jones
Ed Hankins
Stanley Kellar
Thomas Hart
David King
T. S. Harris
Dean Kumpuris
Tim Hodges
Marvin Leibovich
Jerry Holton
Stephen Magie
Harold Hutson
Jane McKinnon
Ben Johnson
Valerie McNee
Dianne Johnson
Rickey Medlock
John Jones
Tena Murphy
Joan Kyle
Fred Nagel
Kenneth Martin
George Norton
John Meadors
Carl Raque
Keith Mooney
John Redman
James Morse
Deanna Ruddell
David Mumme
Ashley Ross
James Norton
Ted Saer
Michael Roberson
Frank Sipes
Ian Santoro
Kemp Skokos
Duane Velez
Claudia Tolleson
Randolph (1)
Saline (2)
Sebastian (12)
Randy Ennen
Allen Beachy
Cole Goodman
Mike Berumen
Michael Gwartney
Peter Fleck
David Hunton
David McQanahan
Greg Jones
Steve Nelson
Robert Knox
Stephen Seffense
Claire Price
Michael Standefer
John Swicegood
Timothy Waack
John Wells
Eric Taft
Sevier (1)
St. Francis (1)
Tri-County (1)
Union (3)
Van Buren (1)
John Hall
Harry Starnes
Washington (8)
Charles Sisco
Jim Sharp
Anthony Hui
William McGowan
Sanford Hutson, III
Michael Morse
White (3)
David Covey
Woodruff (1)
Yell (1)
James Maupin
Gene Ring
Volume 93, Number 11 - April 1997
525
1997 House of Delegates
First Meeting, House of Delegates
5:00 p.m., Thursday, May 1
Anna Redman, M.D., Speaker
1. Call to order
2. Introduction of guests
Mrs. Susan Paddock, Field Director,
American Medical Association Alliance
Mrs. Gwen Pappas, President-elect,
Southern Medical Association Auxiliary
Mrs. Ruth Mabry, President, Arkansas
Medical Society Alliance, Pine Bluff
Mrs. Barbara Moody, President-elect,
Arkansas Medical Society Alliance, Salem
3. Adoption of minutes of the 120th Annual Session
as published in the June 1996 issue of The Journal of the
Arkansas Medical Society.
4. Memorials
5. Presentations
6. Old Business
7. New Business
All reports, resolutions, and other items of
business received by the headquarters office
twenty days prior to the meeting shall be in-
cluded in the agenda. Any items of business
received after April 11th, must have two-thirds
consent of attending delegates before introduc-
tion. All items will be referred to reference
committees.
8. Announcement of a vacancy in the Third Congres-
sional District of the Arkansas State Medical Board
9. Address by Randolph D. Smoak, Jr., M.D., Secre-
tary/Treasurer, American Medical Association,
Orangeburg, South Carolina
10. Recess until Saturday
Final Meeting, House of Delegates
10:30 a.m., Saturday, May 3
Anna Redman, M.D., Speaker
1. Call to order
2. Election of officers. Nominations as submitted by
the Nominating Committee:
President-elect; Mike Moody, M.D., Salem
Vice President: Steve Thomason, M.D., Cabot
Treasurer; Lloyd Langston, M.D., Pine Bluff
Secretary: Carlton Chambers, M.D., Harrison
Speaker of the House: Anna Redman, M.D.,
Pine Bluff
Vice Speaker of the House; Kevin Beavers, M.D.,
Russellville
Delegates to the AMA; James Weber, M.D.,
Jacksonville (1/1/98 - 12/31/99)
Alternate Delegate to the AMA: Larry Lawson,
M.D., Paragould (1/1/98 - 12/31/99)
Councilors:
District 1:
District 2:
District 3:
District 4;
District 5:
District 6:
District 7:
District 8:
Joe Stallings, M.D., Jonesboro
Joe Jones, M.D., Blytheville
Lloyd Bess, M.D., Batesville
Dennis Yelvington, M.D., Stuttgart
John Lytle, M.D., Pine Bluff
Richard PUlsbury, M.D., El Dorado
Michael Young, M.D., Prescott
Brenda Powell, M.D., Hot Springs
Joseph Beck, M.D., Little Rock
C. Reid Henry, Jr., M.D., Little Rock
William Jones, M.D., Little Rock
Mayne Parker, M.D., Little Rock
Anthony Johnson, M.D., Little Rock
Samuel Welch, M.D., Little Rock
Anthony Hui, M.D., Fayetteville
Jan Turley, M.D., Rogers
Mike Berumen, M.D., Fort Smith
Paul Wills, M.D., Fort Smith
3. Address by the President of the Arkansas Medical
Society, John Crenshaw, M.D., Pine Bluff
4. Reports of Reference Committees #1 and #2
5. Report of the Council, Gerald Stolz, M.D., Chair-
man (Report covers meetings held during annual session.)
6. New Business
■^Announcement of nominees for the
Arkansas State Medical Board
■^Other new business
District 9:
District 10:
Vacancy in the Third Congressional District,
Arkansas State Medical Board
A vacancy will occur December 31, 1997, in the
Third Congressional District position of the Arkansas
State Medical Board. The term of office will be for
eight years. Members from the counties in the old
congressional district are urged to meet immediately
following the adjournment of the House of Delegates
on Thursday to vote for nominees. Nominations
should be reported to the Society personnel immedi-
ately following the caucuses (only one nomination is
required).
Rhys Williams, M.D., of Harrison is currently
serving the term which will expire in December 1997.
Dr. Williams is eligible to succeed himself.
The Third Congressional District consists of the
following counties: Baxter, Benton, Boone, Carroll,
Crawford, Franklin, Johnson, Logan, Madison, Marion,
Newton, Scott, Searcy, Sebastian, Van Buren, and
Washington.
Council Meetings
The Council will meet at the following times:
Thursday, May 1, 2:00 p.m.
Friday, May 2, 7:30 a.m.
Saturday, May 3, 7:30 a.m. (tentative)
526
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Nominating Committee
Carlton Chambers, M.D., Chairman
The members of the 1996/1997 Nominating Com-
mittee are Drs. A. E. Andrews, Daniel Davidson, Kevin
Hale, Marion McDonald, Robert Nunnally, Merrill
Osborne, Paul Wills, Harold Wilson, John Wilson, and
Carlton Chambers, Chairman.
The Nominating Committee met on Sunday, No-
vember 17, 1996 during the AMS fall meeting and again
by conference call on January 14, 1997. We wish to
present to the Society the following nominees:
President-elect: Mike Moody, M.D., Salem
Vice President: Steve Thomason, M.D., Cabot
Treasurer: Lloyd Langston, M.D., Pine Bluff
Secretary: Carlton Chambers, M.D., Harrison
Speaker of the House: Anna Redman, M.D.,
Pine Bluff
Vice Speaker of the House: Kevin Beavers, M.D.,
Russellville
Delegates to the AMA:
James Weber, M.D., Jacksonville
(1/1/98 - 12/31/99)
Alternate Delegate to the AMA:
Larry Lawson, M.D., Paragould
(1/1/98 - 12/31/99)
Councilors:
District 1:
District 2:
District 3:
District 4:
District 5:
District 6:
District 7:
District 8:
District 9:
District 10:
Joe Stallings, M.D., Jonesboro
Joe Jones, M.D., Blytheville
Lloyd Bess, M.D., Batesville
Dennis Yelvington, M.D., Stuttgart
John Lytle, M.D., Pine Bluff
Richard Pillsbury, M.D., El Dorado
Michael Young, M.D., Prescott
Brenda Powell, M.D., Hot Springs
Joseph Beck, M.D., Little Rock
C. Reid Henry, Jr., M.D., Little Rock
William Jones, M.D., Little Rock
Mayne Parker, M.D., Little Rock
Anthony Johnson, M.D., Little Rock
Samuel Welch, M.D., Little Rock
Anthony Hui, M.D., Fayetteville
Jan Turley, M.D., Rogers
Mike Berumen, M.D., Fort Smith
Paul Wills, M.D., Fort Smith
icol Rosecirch
Culture, Community &
Collaboration
Speakers Include:
Lawrence J. Appel,
Johns Hopkins University
Wendy Campbell,
Campbell and Company
Wayman Cheatham,
Howard University
Elizabeth Fontham,
Stanley S. Scott Cancer Center
Lynn Lichtermann,
University of Tennessee
She^ Mills,
National Cancer Institute
Howard Fishbein, Eldra Perry,
The Gallup Organization University of Tennessee
Ed Fisher, Jim Raczysky,
Washington University University of Alabama
Medical Center
May 5-6, 1997
C.B. Pennington Jr.
Conference & Education Center
Baton Rouge, Louisiana
Sponsored by:
National Cancer Institute
Presented by:
LSU Medical Center
Stanley S. Scott Cancer Center
Pennington Biomedical Research Center
Donna Ryan,
Pennington Biomedical
Research Center
Nancy Simpson,
National Cancer Institute
G. Marie Swanson,
Michigan State University
Sarah Moody Thomas,
Stanley S. Scott Cancer Center
Robert Veith,
LSU Medical Center
Visit New Orleans
^ \Mayl-4!
Registration: $95, if before April 25
For more information, call (504) 763-2599, e-mail phillibh@mhs.pbrc.edu
or write Ben Phillips, Pennington Biomedical Research Center,
6400 Perkins Road, Baton Rouge, LA 70808
Visit our Website at www.pbrc.edu
Volume 93, Number 11 - April 1997
527
1997 Reference Committees
Reference Committees
Reference Committees are appointed by the Speaker of the House of Delegates to consider the various reports
and resolutions. Reports published in the April issue of The Journal, as well as any reports and resolutions
presented at the first meeting of the House on May 1st, will be referred by the Speaker to the reference commit-
tees. The committees will hold open hearings at 9:30 a.m. on Friday, May 2nd. After the opening hearings, the
reference committees will hold executive sessions for the purpose of preparing recommendations and reports for
the House of Delegates. Reports of the Reference Committees will be acted upon by the House of Delegates at the
Saturday session.
Reference Committee Orientation
There will be a meeting of all reference committee members on Friday, May 2, at 9:00 a.m. The meeting will
be to familiarize the reference committees with the rules, procedures, and writing of the reference committee
reports.
Reference Committee Agendas
Reference Committee #1
9:30 a.m., Friday, May 2, 1997
David Murphy, M.D.
Reference Committee Chairman
AGENDA
1. Annual Session Committee
Jerry Mann, M.D. Chairman
2. Arkansas Medical Society 1997 Budget
Gerald Stolz, M.D., Chairman
3. CME Accreditation Committee
Steve Strode, M.D., Chairman
4. Report of the Council
Gerald Stolz, M.D., Chairman
5. Executive Vice President Report
Ken LaMastus, CAE, Executive Vice President
6. Physicians' Health Committee
Joe Martindale, M.D., Chairman
7. Young Physician's Leadership Task Force
Anna Redman, Chairman
Reference Committee #2
9:30 a.m., Friday, May 2, 1997
Omar Atiq, M.D.
Reference Committee Chairman
AGENDA
1. Medical Education Foundation for Arkansas
Martin Eisele, M.D., President
2. Medical Services Review Committee
Joe Stallings, M.D., Chairman
3. AMS Medical Student Section
Joel Milligan, President
4. Pulaski County Medical Society
Fred Reddoch, Executive Director
5. Arkansas Department of Health
Sandra Nichols, M.D., Director
6. Arkansas Health Care Access Foundation
Pat Keller, Director
7. Arkansas State Medical Board
Peggy Pryor Cryer, Executive Secretary
528
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Business Reports
Reports for Reference Committee #1
Annual Session Committee
Jerry Mann, M.D., Chairman
"Mastering Medicine's Challenges" was the theme
for the 1996 AMS annual meeting. The convention
was off to a great start with Lonnie R. Bristow, M.D.,
President of the AMA, speaking at the opening House
of Delegates. Dr. Bristow, an internist from San Pablo,
California, has been a member of the AMA Board of
Trustees since 1985.
The educational programs began with "Staying Out
of Court" a workshop for young physicians focusing
on mistakes physicians make that cause loss of prac-
tice time due to legal problems. Feature sessions at-
tended by over 200 physicians included "A Patient's
Right to Know... Curbing the Abuses of Managed
Care," "Personal Political Power," "Infectious Diseases:
An Arkansas Focus," and "Managed Care: Confront-
ing and Dealing with the New Realities."
Over 70 companies exhibited their products and
services. Several educational grants were received and
many activities were sponsored by some of these or-
ganizations. The members of the Arkansas Medical
Society appreciate the support from these companies
which helps make the convention possible.
The inaugural banquet was held on Friday evening
and John Crenshaw, M.D., of Pine Bluff, was inducted
as the 1996/1997 AMS president. Officers and council-
ors were elected at the House of Delegates meeting on
Saturday. The meeting concluded at 12:30 p.m. and
several specialty groups met in the afternoon.
Arkansas Medical Society 1997 Budget
Gerald Stolz, M.D., Chairman
Expenses:
Salaries
Travel & Convention
President's Account
Taxes
Retirement
Stationery & Printing
Office Supplies & Expenses
Telephone
Rent
Postage
Insurance & Bonds
Auditing
Council & Executive Committee
Journal & Directory Expense
Dues & Subscriptions
Gifts & Contributions
Alliance
Legal Services (retainer)
Committee / District Meeting
Public Relations
Miscellaneous Expenses
Office Equipment & Furniture
Continuing Medical Education
Richmond Early Retirement
Contract Labor
Winter Meeting
Resident & Student Section
Annual Session
Educational Programs
Physicians Health Committee
MEFFA -Dues
Legal Guide
TOTAL
Income
Dues
Journal Advertising
Booth
Annual Session
AMA Reimbursement
Directory & Miscellaneous
Interest Income
Specialty Desk
Continuing Medical Education
Allocation of G.A. Department
Educational Programs
Legal Guide
TOTAL
Amount
$730,000.00
87.000. 00
37.000. 00
37.000. 00
13.000. 00
15,500.00
50.000. 00
1,620.00
7,200.00
5,000.00
40.000. 00
25.000. 00
$1,048,320.00
Governmental Affairs Budget
Income:
Dues
Miscellaneous Projects
TOTAL
Expenses:
Salaries
Retirement
Taxes
Stationery & Printing
Office Sup, Telephone,
Equipment & Furniture
Auto, Travel & Meeting
$295,585.00
45.000. 00
5.000. 00
24.000. 00
35.946.00
15.000. 00
28.000. 00
11,000.00
79,672.05
30.000. 00
47.000. 00
6.000. 00
4.000. 00
82.000. 00
6.000. 00
2.500.00
8.700.00
27.426.00
7.700.00
3.000. 00
5.000. 00
16,000.00
4.800.00
5.820.00
5.000. 00
0.00
6.000. 00
75.000. 00
20.000. 00
10,000.00
13,000.00
5,000.00
$929,149.05
$245,000.00
2,000.00
$247,000.00
$117,937.00
14,013.00
8,600.00
9,000.00
6,600.00
1,500.00
40,000.00
Volume 93, Number 11 - April 1997
529
Legal Retainer 18,300.00
Postage 20,000.00
Insurance & Bonds 9,800.00
Office Allocation To AMS 5,000.00
PPA - Expenses Coalition 2,000.00
Audit 1,500.00
TOTAL $254,250.00
CME Accreditation Committee
Steve Strode, M.D., Chairman
The Arkansas Medical Society is the official ac-
crediting body for organizations that provide or spon-
sor continuing medical education for physicians within
the state of Arkansas. The Arkansas Medical Society
was awarded continued recognition for a period of four
years by the Accreditation Council for Continuing
Medical Education (ACCME) on September 7, 1995.
The accreditation activities are carried out by the
CME Accreditation Committee which currently con-
sists of Drs. Sanford Hutson, Charles Mabry, Carlton
Chambers, Morton Wilson, and myself. Kay Waldo
and David Wroten of the AMS provide the adminis-
trative support necessary to fulfill our mission.
During the past year the committee reviewed two
organizations, both hospitals, for reaccreditation. The
results were probationary status for one year for one
hospital and four years full accreditation for the other
hospital. One hospital voluntarily withdrew from the
program. A total of eight hospitals are accredited.
The accreditation organizations are required to
submit an annual report every January. These are re-
viewed by the AMS staff and summaries are presented
to the committee for their approval.
The committee is in need of experienced survey-
ors or physicians interested in learning to conduct
surveys. Usually no more than two or three surveys
are conducted per year and each one takes approxi-
mately one-half day. The surveyors are paid $100.00
per survey plus mileage. Committee meetings are held
on an as needed basis, usually quarterly. Anyone in-
terested in the continuing medical education accredi-
tation program should contact David Wroten or Kay Waldo.
My sincerest thanks to the committee members
and staff for the hard work they all contribute to this
process.
Report of the Council
Gerald Stolz, M.D., Chairman
AMS Council:
The Council met on Sunday, March 31, 1996, at
the Pleasant Valley Country Club in Little Rock and
the following business was received and transacted:
1. The Council approved the minutes from the Octo-
ber 29, 1995 Council meeting.
530
2. The Council approved the minutes from the Octo-
ber 25, 1995 Executive Committee meeting.
3. The Council approved the minutes from the De-
cember 13, 1995 Executive Committee meeting.
4. The Council approved the minutes from the Janu-
ary 24, 1996 Executive Committee meeting.
5. The Council approved the minutes from the Eeb-
ruary 27, 1996 Executive Committee meeting.
6. The Arkansas Medical Society membership and
budget reports were accepted for information.
7. Upon motion, the Council approved changes to
the Arkansas Medical Society Alliance bylaws.
8. Upon motion, the Council granted approval for
Dr. Brenda Powell of Hot Springs to fill the unex-
pired term of Dr. Thomas Hollis as a councilor
from the seventh district.
9. Upon motion, the Council granted approval for
Dr. William McGowan to fill the unexpired term
of Dr. Janet Titus as a councilor from the ninth
district.
10. Dr. William Golden discussed his candidacy for
the AMA Board of Trustees. Upon motion, the
Gouncil approved the endorsement of Dr. Golden.
11. Dr. William Jones gave an update on his candi-
dacy for a position on the AMA's Council on Sci-
entific Affairs. The election will be held in June at
the AMA annual meeting.
12. Dr. John Burge gave a report on the AMA interim
meeting held in December in Washington, D.C.
Dr. Burge discussed the AMA's possible reorgani-
zation to include delegates representing specialty
organizations. The Council instructed that a copy
of the Report of the Eederation be mailed to all
Council members for their review prior to the next
Council meeting.
13. Lynn Zeno gave an update on the AMA Leader-
ship Conference in which he and Drs. Mike
Moody, Carlton Chambers, William Golden, Wil-
liam Jones, Robert McCrary, and Parthasarathy
Vasudevan attended.
14. David Wroten gave an update on the Arkansas
Workers' Compensation Commission activities.
Public hearings were held recently to discuss man-
dated MCO's and the Commission has reversed
their decision on this issue.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
15. Mike Mitchell and Ken LaMastus made a proposal
to publish a Doctors' Legal Guide containing medi-
cally related laws in Arkansas. The estimated cost
for this project is $27,000.00. Upon motion, the
Council approved this project.
16. The Council discussed a request from the Arkan-
sas Sleep Disorders Society to have a representa-
tive to the Medical Services Review Committee
(MSRC). The Council felt this was not necessary
at this time and a representative could be called
upon if ever needed. A letter will be written to
Dr. Joe Stallings, Chairman of the Medical Ser-
vices Review Committee, stating the Council's
decision in this matter and Dr. Stallings, as Chair-
man of the MSRC, can respond to the group.
17. Dr. Glen Baker discussed the Arkansas State Medi-
cal Board's requirement for physicians to be li-
censed in Arkansas to perform tests for Arkansas
residents. There was no action necessary for the
Council as the Arkansas State Medical Board will
address this issue.
18. Janell Mason gave an update on the AMS Man-
agement Company and discussed the proposals
to be presented immediately following the Coun-
cil meeting. Janell estimated the AMS Manage-
ment Company has approximately three months
capital remaining.
19. Dr. John Crenshaw informed everyone of the
President's Club meeting to be held on Wednes-
day, May 1, in conjunction with the Arkansas
Medical Society's annual meeting.
20. Dr. Glen Baker gave an update on the Arkansas
Medical Foundation. The bylaws have been ap-
proved and officers have been selected.
The Council adjourned to reconvene in executive
session. Minutes of executive sessions are available
for review by any member at the AMS office.
The Council met May 2-3, 1996, at the Excelsior
Hotel in Little Rock and the following business was
received and transacted:
1. Dr. Larry Lawson explained the recommendation
from the AMS Management Company Board re-
garding the sale of the assets of the AMS Manage-
ment Company. Consultant Bill Loweth stated
this transaction should allow the Arkansas Medi-
cal Society to recover the initial investment. THG
would be able to offer more services and support
the current AMCO's. The Council members dis-
cussed the options and consequences regarding
this transaction.
Upon motion the Council approved a resolution
authorizing the Board of Directors of the AMS
Management Company to 1) sign a letter of intent
with THG Management Services for the purchase
of the AMS Management Company and complete
the sale according to those terms; 2) authorize the
Board to take the necessary steps to dissolve the
corporation; and 3) encourage the AMCO's to
execute new management agreements with THG
Management Services.
2. Upon motion the Council approved the minutes
of the March 31, 1996 Council meeting.
3. The following reports were accepted for informa-
tion: AMS Membership Report; AMS Budget
Report; AMS Audit for 1995; and MEFFA Audit
for 1995.
4. Dr. Lonnie Bristow, President of the American
Medical Association, greeted the Council members
and briefly discussed legislative issues in Wash-
ington including anti-trust. Medical Savings Ac-
counts, and professional liability reform. Dr.
Bristow also discussed the report of the Federa-
tion.
5. Dr. William Jones discussed the AMA's recent
announcement concerning the divestment of all
tobacco related stocks, bonds, and mutual funds.
Upon motion, the Council voted for the Budget
Committee to undertake a comprehensive study
of investment portfolios of the Arkansas Medical
Society, the AMS Pension Plan, and MEFFA to
determine every instance where our monies are
invested in tobacco companies, their subsidiaries,
and/or mutual funds holding tobacco stocks and
bonds; and that a report be made to the Council at
our next meeting at which time the Council will
consider divestment of all tobacco related stocks,
bonds, and mutual funds.
6. Dr. Glen Baker gave an update on the new foun-
dation for the Physicians' Health Committee, the
Arkansas Medical Foundation. The Foundation
will oversee the Physicians' Health Committee and
funding that activity. Dr. Martindale will serve as
director. Board members are Dr. Glen Baker, Presi-
dent; Dr. Larry Lawson, Vice President; Karen
Ballard, Secretary/Treasurer; Dr. Joanna Seibert;
and one doctor of osteopathy yet to be named.
Volume 93, Number 11 - April 1997
531
7. Dr. William Jones discussed the new Medicare
HMO techniques for credentialing physicians by
requesting to review random office charts. Upon
motion the Council voted to refer this issue to the
Arkansas State Medical Board for investigation to
determine if this represents a breach of medical
ethics and the Medical Practices Act.
8. The Council elected Dr. Anna Redman, Dr. Tim
Langford, and Dr. Jerrel Fontenot to serve as an
ad hoc committee to make recommendations to
reorganize the Young Physicians Committee.
9. The Council made the following committee ap-
pointments:
Budget Committee: Gerald Stolz, Russellville and
Robert McCrary, Hot Springs
Journal Editorial Board: reappointed Ben
Saltzman, Mountain Home, family practice and
reappointed Lee Abel, Little Rock, intemail medicine
Medical Education Foundation for Arkansas: re-
appointed Martin Eisele, Hot Springs
Arkansas Medical Society Pension Plan Board of
Trustees: Wayne Elliott, El Dorado
Committee on Position Papers: reappointed Roger
Cagle, Paragould, Chairman; reappointed Paul
Wills, Fort Smith; reappointed Paul Wallick,
Monticello; reappointed Martin Fiser, Little Rock;
and reappointed Peter Marvin, North Little Rock.
Medical Services Review Committee:
Family Practice: Kerry Pennington, Warren
General Surgery: Samuel Landrum, Fort Smith
Obstetrics/Gynecology: Karen Kozlowski, Little Rock
Internal Medidne & Pediatric Representatives: posi-
tions open pending reports from their organizations.
Pathology: Gerald Stolz, Russellville
Orthopaedic Surgery: David Newbern, Little Rock
MSRC Subcommittee of Subspecialties:
Emergency Medicine: James Tutton, Benton
Nephrology: Ronald Hughes, Little Rock
Pediatric Allergy: Joseph Matthews, Little Rock
Physicians' Advisory Committee to Medicare:
Emergency Medicine: James Tutton, Benton
Family Practice: Kerry Pennington, Warren
General Surgery: Samuel Landrum, Fort Smith
Nephrology: Ronald Hughes, Little Rock
Obstetrics/Gynecology: Janet Cathy, Little Rock
Orthopaedic Surgery: D. Gordon Newbern, Little Rock
Pathology: Gerald Stolz, Russellville
Pediatric Representative: position open pending
report from their organization
Physicians' Health Committee: Stacey Johnson,
Mountain Home
10. Upon motion the Council approved a change to
the bylaws for the Physicians Advisory Commit-
tee for a term of three years and a member cannot
serve more than one term. This will coincide with
the MSRC bylaws.
11. Dr. John Burge discussed the Report of the AMA
Federation to be voted on at the AMA House of
Delegates meeting in June and encouraged every-
one to give the AMS delegates their comments
before the meeting.
12. Upon motion the Council approved requests for
dues exemption for life, emeritus, and affiliate
memberships.
The Council met at noon on Sunday, August 25,
1996, at the Pleasant Valley Country Club in Little
Rock and the following business was received and
transacted:
1. Upon motion the Council approved the minutes
of the May 2-3, 1996 Council meetings.
2. Upon motion the Council approved the minutes
of the June 27, 1996 Executive Committee confer-
ence call.
3. Upon motion the Council approved the minutes
of the July 24, 1996 Executive Committee meeting.
4. Upon motion the Council gave its approval for Dr.
James M. Kolb, Jr. to fill the unexpired term of Dr.
James Armstrong on the Executive Committee. Dr.
Armstrong was the Immediate Past President of
the Arkansas Medical Society.
5. David Ivers gave an update on the Patient Protec-
tion Act Lawsuit. A ruling from the judge is ex-
pected in a couple of months. Mr. Ivers did not
believe there would be a trial.
6. David Wroten gave a presentation on behalf of Dr.
Anna Redman, Chairperson of the Young Physi-
cians Committee. Upon motion the Council voted
to accept Dr. Redman's proposals as submitted
which include a committee structure change and
renaming the committee the Young Physicians
Leadership Task Force.
532
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
7. David Wroten discussed the Arkansas State Medi-
cal Board's proposed regulation regarding CME
requirements for licensure. Upon motion the
Council voted to ask the board to consider accept-
ing specialty board certifications as meeting the
requirements and to consider an exemption for
retired physicians.
8. Dr. John Burge gave a report on the AMA meet-
ing held in Chicago in June. He explained the
reorganization of the AMA House of Delegates will
include more specialty representation. This should
not affect the Arkansas Medical Society. Upon
motion, the Council referred a proposal to the
Budget Committee that would allow alternate del-
egates to attend two AMA meetings a year rather
than one.
9. Upon motion the Council gave its approval for Dr.
Samuel Welch of Little Rock to fill the unexpired
term of Dr. Charles Logan as an Eighth District
Councilor. Dr. Logan is President-elect of the
Arkansas Medical Society.
10. Upon motion the Council gave its approval for Dr.
Paul Wills of Fort Smith to fill Dr. Gerald Stolz'
unexpired term on the AMS Nominating Commit-
tee. Dr. Stolz is the chairman of the Council.
11. Chairman Stolz discussed the scheduling of Coun-
cil meehngs. Dr. Stolz will appoint an ad hoc com-
mittee to consider alternatives to meeting on Sun-
day at noon.
12. Dr. Larry Lawson gave an update on the sale of
the AMS Management Company. The sale of the
company has been completed. The Arkansas
Medical Society has received $100,000 of the
$300,000 originally invested and expects to receive
additional funds at a later date.
13. The Council gave its approval for Dr. Charles Ball
of Fayetteville to serve on the Medical Services
Review Committee to represent Pediatrics.
14. Lynn Zeno reported on the Arkansas Health Care
Coalition established to ensure health care cost
containment and oppose anything they consider
anti-managed care. Several large employer groups
and insurance companies have joined this coalition.
15. Chairman Stolz discussed plans for the Arkansas
Medical Society Fall Meeting scheduled for No-
vember 16-17, 1996 at the Lake Hamilton Resort in
Hot Springs and encouraged everyone to attend.
16. Ken LaMastus discussed the information received
from Boatmen's Trust Company regarding invest-
ment of all tobacco related stocks, bonds, and
mutual funds. The Council approved the follow-
ing motions submitted by Dr. William Jones:
The Arkansas Medical Society Council send a
letter of commendation to the President of the
United States Bill Clinton and the Commissioner
of the Food and Drug Administration, David
Kessler, for their leadership roles in the fight to
reduce teenage use of tobacco products, and the
recognition of nicotine as an addictive drug con-
tained in tobacco that is responsible for the pre-
mature death of over 400,000 United States citi-
zens each year and that copies of these letters be
forwarded to the Board of Trustees of the Ameri-
can Medical Association.
The Arkansas Medical Society Council instruct
the Budget Committee to carry out the divestment
of tobacco related stocks, bonds, and mutual funds
contained in the portfolio of the Arkansas Medical
Society, the AMS Pension Plan, and MEFFA with
due consideration to the suggestions outlined in
the August 1, 1996 letter from Boatmen's Vice Presi-
dent Pat D. Moon.
Any future investments of the Arkansas Medi-
cal Society controlled funds exclude the purchase
of any tobacco related stocks, bonds, or mutual
funds. The tobacco investment action taken be
reported to the American Medical Association
Board of Trustees and the American Medical News.
These actions shall be reported to the Arkansas
Medical Society membership in the next newslet-
ter and in a future publication of The Journal of the
Arkansas Medical Society and the report shall indi-
cate the Arkansas Medical Society Council's en-
couragement of the membership to take similar
action in regard to their individual investment
portfolios.
17. Ken LaMastus reported on a coalition consisting
of UAMS, the American Cancer Society, the Ar-
kansas Department of Health, the American Lung
Association, the American Heart Association, and
others, that will apply for a Robert Woods Johnson
Foundation grant to help combat teenage smok-
ing. The grant would be for $800,000 over a four-
year period. The Arkansas Medical Society has
been asked to be the lead organization.
Joel Milligan, President of the AMS Medical Stu-
dent Section, offered support from the Medical
Student Section to speak to teenagers and educate
them on the dangers of tobacco.
18. Dr. Joe Stallings discussed the ever increasing use
Volume 93, Number 11 - April 1997
533
of appetite suppressant drugs prescribed by phy-
sicians and whether the Arkansas Medical Society
should have a position on this issue. Upon mo-
tion the Council voted to refer this to the Position
Papers Committee and for the Position Papers Com-
mittee to report on this at the spring meeting.
The Council met November 16-17, 1996 at the
Lake Hamilton Resort in Hot Springs, Arkansas and
the following business was received and transacted
on November 16, 1996;
1. Upon motion the Council approved the August
25, 1996 Council minutes.
2. Letters of commendation to the President of the
United States and the Commissioner of the Food
and Drug Administration for their leadership roles
in the fight to reduce teenage use of tobacco prod-
ucts, and the recognition of nicotine as an addic-
tive drug were presented for information. A letter
informing the AMA of the Arkansas Medical
Society's decision to divest any of its holdings in
tobacco stocks was also presented for information.
3. David Wroten discussed the concerns of the Ar-
kansas Department of Human Services' regarding
the renewal of the hospital obstetrics waiver.
4. Upon motion Dr. Anna Redman of Pine Bluff was
elected as an AMA alternate delegate replacing Dr.
James Kolb. Dr. Kolb received a standing ovation
for his dedication and hard work.
5. Upon motion Dr. Anthony Hui of Fayetteville was
elected to fill the unexpired term of Dr. David Davis
who recently resigned as a Ninth District Councilor.
6. Upon motion the Council voted to fill two vacan-
cies in the Medical Services Review Committee.
Dr. Terry Green of Dardanelle will represent or-
thopaedic surgery and Dr. Ron Hughes of Little
Rock will represent internal medicine. Dr. Green
was also elected to serve on the Arkansas Medi-
care Carrier Advisory Committee.
7. Dr. Robert McCrary reported on the results of a
recent survey of officers and councilors to deter-
mine the best day and time for Council meetings.
Dr. McCrary reported the vast majority of re-
sponses indicated a desire to continue to hold
meetings on Sundays at noon. Upon motion the
Council voted to accept the report and continue
with Sunday meetings.
8. Dr. Carlton Chambers reported on the Southeast
Continuing Medical Education Symposium hosted
by the Arkansas Medical Society in October in Little
Rock. The meeting was attended by CME profes-
sionals, hospital staff, and physicians from Arkan-
sas, Louisiana, Alabama, and Mississippi. Dr.
Chambers reported it was an excellent program
with national speakers and was very informative.
9. Dr. John Crenshaw reported the first annual meet-
ing of the nursing facility medical directors and
administrators sponsored by the Arkansas Health
Care Association and the Arkansas Medical Soci-
ety had recently been held in Little Rock. The
meeting was well attended and Dr. Crenshaw felt
there is definitely a need to continue with annual
meetings.
The Council adjourned to reconvene into Execu-
tive Session on Sunday, November 17, 1997. Minutes
of executive sessions are available for review by any
AMS member at the Society office.
AMS Executive Committee:
The Executive Committee met on Wednesday,
January 24, 1996, at the Arkansas Medical Society
office in Little Rock and the following business was
received and transacted:
1. The Executive Committee received an update on
the Patient Protection Act lawsuit. The attorneys
have until March 25 to complete discovery. The
trial date is set for May 20 in Judge Moody's court.
Mike Mitchell expects a decision sometime in June.
2. The Executive Committee received an update from
David Wroten on the Workers' Compensation Com-
mission requirements for continuing medical edu-
cation. He also discussed concerns by insurance
companies regarding the mandatory managed care
organization requirements. David reported that
no where in the law does it mention this being
mandatory.
3. The Executive Committee discussed the AMA
Leadership Conference to be held in March. The
Executive Committee gave its approval for three
members and one staff person to attend the con-
ference and for the Society to pay Dr. William Jones'
registration fee with the remainder to come from
his campaign funds.
4. The Executive Committee reviewed a request for
membership in the Arkansas Tort Reform Asso-
ciation (ATRA). The Society paid $5,000.00 last
year to join ATRA when legislation on tort reform
was expected to be introduced in the legislature.
The Executive Committee asked Ken LaMastus to
review this matter and consider a lower contribution.
534
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
5. The Executive Committee discussed endorsing
Autoflex Leasing Company. This would be a five-
year commitment and would be managed through
AMS Benefits. The agreement includes advertis-
ing in the journal and membership directory, sup-
port at the annual convention, and $100.00 per
automobile leased or purchased by Arkansas phy-
sicians. The Texas, Oklahoma, and the Pennsyl-
vania Medical Associations also endorse Autoflex
Leasing. Currently some AMS members purchase
their vehicles through Autoflex and are satisfied
with their services. The AMS recently purchased
a company automobile through Autoflex and the
savings were approximately $800.00 over other
companies. The Executive Committee gave its
approval for endorsement of Autoflex Leasing
Company.
6. The Executive Committee discussed preparing a
legal guide containing all the medically related laws
in Arkansas. Mr. Mitchell indicated he has a law
clerk who could spend the summer working on
this project instead of one of the law partners which
would be a considerable savings for the Society.
The Executive Committee recommended this be
referred to the Council at its next meeting with
estimates on the cost of preparing the guide and
estimated sale price.
7. The Executive Committee reviewed information
concerning leasing a portion of the AMS Manage-
ment Company suite. This cost of preparing part
of the suite to be leased could be as high as $10,000
to $11,000. There are potential tenants who have
expressed interest in the space. The Executive
Committee recommended that we proceed with
leasing the unused portion of the AMS Manage-
ment Company suite.
8. The Executive Committee approved a list of phy-
sicians requesting direct membership into the Ar-
kansas Medical Society.
9. Dr. John Crenshaw recommended that we con-
tact Dr. James Adamson at Arkansas Blue Cross
Blue Shield and ask him to provide a list of MSRC
and Medicare Advisory Committee members who
have missed two consecutive meetings or one-half
of the meetings per calendar year. This would help
us and the specialty groups in appointing physi-
cians to serve on these two committees.
The Executive Committee of the Arkansas Medi-
cal Society met briefly on Tuesday evening, Febru-
ary 27, 1996, at the Arkansas Medical Society office
in Little Rock and the following business was re-
ceived and transacted:
1. The Executive Committee reviewed proposed
changes in the Arkansas Medical Society Alliance
Bylaws. These bylaws will be included in the
agenda for the next Council meeting.
2. The Executive Committee discussed the concerns
of physicians in Northwest Arkansas about AMCO
contracting with the closed panel PHO at Wash-
ington Regional Medical Center in Fayetteville. It
was decided that the members of the AMS Execu-
tive Committee would meet with representatives
of the Northwest Arkansas IPA to discuss this
matter.
The Executive Committee met at 3:00 p.m., Thurs-
day, June 27, 1996, by conference call and the fol-
lowing business was received and transacted:
1. The Executive Committee voted unanimously to
send a letter to Lt. Governor Mike Huckabee en-
dorsing Dr. Sandra Nichols, as Director of the
Arkansas Department of Health.
2. David Wroten discussed closing the AMS Benefits
trust. It has been over one year since the insur-
ance program was turned over to American In-
vestors Life Insurance Company. The Executive
Committee voted to close the trust. (The Execu-
tive Committee and three AMS staff members are
the board of directors of AMS Benefits, Inc.)
3. Dr. Gerald Stolz discussed the date for the next
Council meeting, August 25. A Council retreat
was also discussed. With so many new council-
ors a retreat would allow time for explaining some
additional functions of the Arkansas Medical So-
ciety and give the new councilors a chance to ask
questions. There was discussion on having this
retreat in conjunction with the fall meeting, No-
vember 16-17.
4. Ken LaMastus asked for permission to attend the
American Society of Association Executives (ASAE)
national meeting. He indicated we normally send
two staff members to the American Association of
Medical Society Executives (AAMSE) annual meet-
ing. Instead of attending the AAMSE meeting he
would like to attend the ASAE meeting in order to
obtain continuing education credit for his Certi-
fied Association Executive recertification. This
request was approved.
5. Two letters were received by the Executive Com-
mittee pertaining to problems at the Jefferson Re-
gional Medical Center's emergency department
with inmates from the Arkansas Department of
Corrections being sent there for emergency care
Volume 93, Number 11 - April 1997
535
and to Little Rock for routine care. This issue was
referred to the Executive Committee for informa-
tion only.
6. The Executive Committee reviewed a letter from
Dr. Joe Beck, Chairman of the AMS Committee
on AIDS. The Executive Committee accepted Dr.
Beck's recommendation to keep the Committee on
AIDS intact so it would be available if there was a
positive HIV in a physician. The committee is
inactive at this time.
7. Dr. John Crenshaw discussed other committees
appointed by the AMS President. Dr. Crenshaw
indicated he would contact Dr. Jerry Mann to see
if he would continue to serve as Chairman of the
Annual Session Committee. Dr. Crenshaw rec-
ommended that the Task Force on Smoking and
Tobacco Products and the Committee on Health
Care Reform be disband. The Committee on Health
Care Reform is the committee that looked into es-
tablishing a managed care organization. The Ad
hoc Committee on Managed Care, chaired by Dr.
Glen Baker, will be left intact.
8. The Executive Committee discussed a recommen-
dation by the Arkansas Tobacco Free Coalition
(American Lung Association, American Heart As-
sociation, American Cancer Society, etc.) to be the
lead sponsor in applying for a grant from the Rob-
ert Woods Johnson Foundation. The Executive
Committee decided that the AMS staff should look
into this further and report their findings to the
Executive Committee.
The Executive Committee on Wednesday, July
24, 1996, at the Arkansas Medical Society office in
Little Rock and the following business was received
and transacted:
1. Ken LaMastus discussed the possibility of the Ar-
kansas Medical Society being the lead organiza-
tion of a coalition established to obtain a grant from
the Robert Woods Johnson Foundation to prevent
tobacco use among teenagers. The Arkansas Medi-
cal Society would be committed to working with
physicians in this effort. One of the lead
organization's responsibility is keeping up with
the grant money. Other members of the coalition
are the American Heart Association, the Ameri-
can Lung Association, the American Cancer Soci-
ety, the Arkansas Department of Health, etc. The
Executive Committee suggested that more infor-
mation be obtained and reported to the Council at
its next meeting.
536
2. Pulaski County Medical Society has nominated Dr.
Samuel Welch of Little Rock as an Eighth District
Councilor to replace Dr. Charles Logan who was
elected President-elect of the Arkansas Medical
Society.
3. A list of physicians requesting emeritus and direct
membership was approved.
4. The Executive Committee requested a letter be sent
to Mrs. Armstrong from Dr. Crenshaw express-
ing the Arkansas Medical Society's sorrow at the
loss of Dr. James Armstrong.
5. Ken LaMastus discussed efforts between the Ar-
kansas Medical Society and the Arkansas Health
Care Association (Nursing Home Association) to
develop a seminar for medical directors and nurs-
ing home administrators. Dr. Crenshaw who is a
medical director addressed this issue. Dr.
Crenshaw will head a committee of medical doc-
tors who will work with nursing home adminis-
trators to establish topics for the seminar.
Executive Vice President Report
Ken LaMastus, CAE
As we move into the second quarter of 1997, man-
aged care in its various forms is rapidly becoming more
of a factor in the way health care is financed in Arkan-
sas, as well as the way it is being delivered. At the
beginning of 1997, there were nine HMOs registered
with the Arkansas Department of Health with 170,000
people enrolled. According to Arkansas Business, there
were thirteen PPOs and numerous PHOs. Approxi-
mately 675,000 people are enrolled in PPOs, a signifi-
cant portion of the insured population of the state.
The majority of the hospitals have some affiliation with
other hospitals.
It is reported that few, if any, of the HMOs are
much above the break-even point in terms of profit.
Three Arkansas HMOs are planning to enroll Medi-
care patients in their programs. As competition for
the Medicare patients increase, you can assume the
benefits of the HMOs to the Medicare population will
increase. Currently, Medicare HMOs are reimbursed
by Medicare at 95% of the average health care cost for
each enrollee. The counties with the highest Medicare
costs are the ones with larger cities and surrounding
areas. HMOs are attempting to enroll this population.
There was a recent article in the Arkansas Democrat
Gazette stating that Medicare is considering increasing
to some minimum level the compensation made to
HMOs in some of the lower health care cost rural ar-
eas. The amount of money involved was not enough
to attract the HMOs to enroll people in these rural
counties. This makes you wonder about the federal
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
government's concern about the cost of health care.
The 1995 Arkansas General Assembly passed the
"Any Willing Provider" law. Prudential Insurance
Company and Arkansas Blue Cross and Blue Shield
are attempting to have this overthrown. Federal Judge
Moody heard the Prudential case and ruled in their
favor. Attorneys for the Arkansas Medical Society felt
this was not a reasonable ruling for a number of rea-
sons, and the case has been appealed to the Eighth
Circuit Court. The "Any Willing Provider" legislation
was passed by an overwhelming majority in the leg-
islature. Elected officials heard from their constituents
that they preferred to be able to select doctors of their
choice.
As of the writing of this report, the 1997 Arkansas
General Assembly is still in session. There is a large
number of bills of interest to the physician commu-
nity. Still under consideration, but not yet heard be-
fore a committee, is the "Patient Protection Act II"
which has significant benefits for the public, as well
as, the medical community. Some of the features of
this bill include doing away with the gag rule, and
drive by deliveries and mastectomies. It is apparent
that some portions of this legislation will be passed.
Early attempts to do away with the "Soda Pop" tax
used for Medicaid have been dropped.
The House of Representatives has removed the
requirements for wearing a motorcycle helmet for those
over 21 years of age. At this time, the governor has
not signed the bill. Some of the following comical notes
concerning the motorcycle helmet law have been heard
from the legislators. One legislator said he did not
know why people would be concerned about allow-
ing those over 21 years of age to ride a motorcycle
without a helmet. He was heard saying this would
improve the gene pool. Another legislator was heard
saying this would also improve the number of organs
available for transplants.
Changes in the Medicaid program are being dis-
cussed in part due to efforts of the governor to cut
state spending. We have been fortunate for the last
two to three years to have one of the best Medicaid
programs in the nation. This is partially due to the
lawsuit won by the Society. Some efforts have been
made to put the program in an HMO. However, no
HMO has stepped forward that can match the state in
its low cost of administration of the program.
The Arkansas Medical Society anticipates having
a web site available for those interested in the Internet.
We are working with one of the premiere providers of
these services in Arkansas to develop a web site. This
would be beneficial to Arkansas physicians and allow
our members to receive more information.
The Society continues to offer educational work-
shops and seminars for physicians, clinic managers,
and office staff. The workshops were very successful
in 1996. The first AMS sponsored workshop for 1997,
"Audit Proof Your Practice" is filled to capacity. Pro-
grams for 1997 include "Managed Care Update" and
"Coding Analysis to Maximize Reimbursement."
The Arkansas Medical Society's membership in
1997 is ahead of 1996. The Medical Society is finan-
cially sound and the AMS Building is managing its
cash flow to the point that it is not a drain on the
Medical Society's resources.
I am proud of the Arkansas Medical Society staff
in the way they have performed over the last year and
am pleased with our members who have taken time
from their busy lives to assume responsible positions
within the Medical Society and help guide the future
of medicine in Arkansas.
It has often been said that the Medical Society will
never have resources to make it capable of being all
things to all physicians. However, the Society is the
one organization that represents all physicians regard-
less of their field of practice.
As there are rapid changes going on in the deliv-
ery of health care services in the state. One thing is
apparent for physicians: they should be a part of the
Arkansas Medical Society and work together. The Ar-
kansas Medical Society needs its membership, the
membership needs the Arkansas Medical Society and,
most of all, physicians of this state need each other to
work together to move through these turbulent years
of change.
Physicians' Health Committee
Joe Martindale, M.D., Chairman
The Physicians Health Committee was established
several years ago by the Arkansas Medical Society to
intervene and assist physicians with substance abuse
problems. During 1996, over 90 impaired physicians
received assistance through the Physicians Health
Committee program. The program is now being
funded through the Arkansas Medical Foundation.
Funding for the foundation comes through the Arkan-
sas State Medical Board from a $20.00 increase in li-
censure fees. A full-time office has been established.
The address is 23157 1-30, Suite 201, Bryant, Arkansas
72022; telephone 847-8088; fax 847-7140. Joe Martindale,
M.D., serves as the medical director and Vicki Walters,
RRA, is the full-time assistant.
Young Physician's Leadership Task Force
Anna T. Redman, M.D., Chairman
In an effort to more effectively address the needs
and concerns of the young physicians of Arkansas,
the council voted at its August meeting to restructure
the Young Physician's Committee into a Young Physi-
cian Leadership Task Force. This smaller group is
charged with developing and implementing a plan to
Volume 93, Number 11 - April 1997
537
encourage stronger participation among other young
physicians in the Society and to disseminate informa-
tion to these young physicians which might be par-
ticularly useful or relevant to their practices.
The task force first met in November, in conjunc-
tion with the fall House of Delegates meeting. The
group made plans to target specific areas of the state
where we each have acquaintances and to personally
contact these people and encourage their attendance
at the annual meeting. The group hopes to educate
our fellow young physicians on the need for participa-
tion and also to educate them on the process involved
in making changes in the Society and its policies. An-
other group we plan to target are third year residents,
to help them make a smooth transition into practice,
and also realize the importance of involvement in the
Society.
We will be sponsoring a seminar in conjunction
with the annual session, entitled "Getting Started in
Medical Practice." The group will meet again during
the annual session and all interested young physician
are invited.
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medicine/preventive care. Send CV and statement of
interest to: Geoffrey Goldsmith, MD, MPH, Department of
Family and Community Medicine. 4301 West Markham, Slot
530, Little Rock, Arkansas 72205-7199.
AFMC Schedules Meeting
The Arkansas Foundation for Medical
Care (AFMC) has scheduled its annual mem-
bership meeting for 2:30 p.m. in the Arlington
Hotel, Hot Springs, on Saturday, May 3, 1997.
Members will elect 7 physician directors, one
representative each from the hospital industry
and the business community to represent them
on AFMC's Board of Directors. Additional
information will be forwarded to members this
month or you may call Patricia Williams at
1-800-272-5528.
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Medical Education Foundation for Arkansas
Martin Eisele, M.D., President
The Medical Education Foundation for Arkansas
was organized by the Arkansas Medical Society in 1959.
It is governed by a board of directors appointed by the
Council of the Arkansas Medical Society. I am privi-
leged to serve as president. Other members of the
board are Drs. William Bishop, James Kyser, and
Gerald Stolz. Serving as ex-officio with voting power
are the Arkansas Medical Society president, president-
elect, immediate past president, and the Dean of the
University of Arkansas College of Medicine.
The Foundation receives funds contributed by the
Arkansas Medical Society which amounts to $5.00 for
each full dues paying member per year. By conserva-
tive investment and expenditures, the Foundation has
grown to a net worth in excess of $400,000. The Foun-
dation has an independent audit each year and a copy
of the audit is provided to the Council. Funds are
used each year to promote the art and science of medi-
cine and the betterment of the health of the public by
providing financial support to recognize schools or
institutions who provide primary and advanced medi-
cal education. The board has established a policy of
accumulating funds over a period of time so in the
future the foundation will have adequate funds to
undertake major projects.
During 1996 the Medical Education Foundation for
Arkansas made the following contributions to the
University of Arkansas College of Medicine:
* $5,000.00 to the Ben Saltzman Endowed Chair in
Rural Family Medicine
* $8,000.00 to the UAMS Distinguished Lecture
Series (10 lectures at $800 each)
* purchased three computer work stations includ-
ing software and networking materials for the
UAMS Department of Pediatrics
* purchased a 7-bay CD ROM tower for the UAMS
Department of Anatomy
Medical Services Review Committee
Joe Stallings^ M.D., Chairman
The Medical Services Review Committee met on
April 24, 1996 and July 24, 1996. The next meeting of
the Medical Services Review Committee is scheduled
for April 23, 1997. The Medicare's development of a
clinical advisory committee has reduced the case load
of the Medical Services Review Committee. The meetings
have been less frequent the last few years.
The efforts exerted by the members of the Medical
Services Review Committee are appreciated by the
Arkansas Medical Society Council and Arkansas Blue
Cross Blue Shield.
AMS Medical Student Section
Joel C. Milligan, President
It is my distinct pleasure to update you with re-
spect to the activities of the UAMS Medical Student
Section of the Arkansas Medical Society and the Ameri-
can Medical Association. I believe that 1996 was an
excellent year for our section for many different rea-
sons. In the area of state membership, we experienced
a 13% increase in the total number of student mem-
bers in the AMS (348 FYE Dec. 1995 compared to 393
FYE Dec. 1996). In the area of national membership,
we experienced a 43% increase in the number of new
members in the AM A (80 FYE Dec. 1995 compared to
114 FYE Dec. 1996). This dramatic increase in our mem-
bership has placed us in a good position with respect
to ability to serve others and ability to communicate
the virtues of organized medicine. As a reward for our
recruitment efforts, the AMA sent our UAMS AMA-
MSS Chapter a check for over $2,300 to be used in
chapter development. As president of our chapter, I
feel it is my duty to start a savings account for the
UAMS-MSS Chapter with this money. This money will
be used by the chapter to attend sectional meetings,
to send more members to the national meetings, to
increase recruitment efforts, and to support local charities.
In the area of local meetings, we were privileged
to have Mr. Lynn Zeno speak to us this past fall about
the medical legislation that is now before Arkansas
Legislature. We were also pleased to have the Director
of the Arkansas Department of Health, Sandra Nichols,
M.D., speak to us about the clinical symptoms and
signs of domestic abuse. Both of these speakers were
very enthusiastic about their topics and did a wonder-
ful job of educating us about these timely topics. We
greatly appreciate the AMS for appropriating funds
for the students' lunches at our bimonthly meetings.
We could not have these meetings without your support!
In the area of national meetings, Rick White, vice-
president of the UAMS AMA/AMS-MSS, and I were
privileged to be funded by the AMS to represent Ar-
kansas at the AMA-MSS national meetings in Chicago,
IL (June 1996) and in Atlanta, GA (December 1996).
Rick and I learned a tremendous amount of information
Volume 93, Number 11 - April 1997
539
about the inner workings of the AMA and how it is
able to serve medical students from their first day at
medical school to the time where they hear their name
followed by "MD." Rick and I have taken many of the
ideas presented at these meetings and used them here
at UAMS to better serve our members.
In the area of projects, Rick White is in the pro-
cess of developing a fund-raiser that will use the money
collected to benefit a worthy charity in our commu-
nity. Vanessa McKinney, Secretary-Treasurer of UAMS
AMA/AMS-MSS, is in the process of acquiring a project
that we as medical students can take to area elemen-
tary schools in order to teach these future doctors how
understanding and using science can help them stay
healthy. I recently completed the process of collecting
medical journals and textbooks for our "Journal
Abroad" project. The purpose of this project is to gather
and send them to a clearinghouse that will ship them
across the world to medical schools and hospitals in
developing countries that are in dire need of current
medical information.
I cannot wait to see what next year brings for our
medical student section of the AMA/AMS. If you would
like more information about our organization or would
like to speak to a group of eager medical students about
a timely topic, please e-mail me at jcmilligan
©life. uams.edu or call (501) 851-8552. Thank you for
your continued support. Have a great year!
Pulaski County Medical Society
Bruce E. Schratz, M.D., President
The Pulaski County Medical Society thrived in 1996
under the distinguished leadership of President Bruce
E. Schratz, M.D. The following activities helped make
the year a memorable one:
■^continued membership growth (955) resulting in
an additional Councilor position
^presentation of four scholarships to UAMS sopho-
more medical students
*membership meeting with Mr. Rex Nelson, Gov.
Huckabee's Director of Policy and Communications
^sponsorship of a seminar on managed care issues
^management of the Pulaski County Medical Ex-
change which processed over 500,000 calls for its 600
subscribers and their patients
*joint meeting with the Pulaski County Bar Asso-
ciation attended by 230 members, spouses and guests
The Society anticipates another successful year in
1997 under our new President, Edward H. Saer, M.D.
Arkansas Department of Health
Sandra B. Nichols, M.D., Director
It is my privilege to present to the Arkansas Medi-
cal Society a summary of the major accomplishments
and activities of the Arkansas Department of Health
in 1996. This has been a very important year for the
540
Arkansas Department of Health. We kicked off an ex-
citing new project - ASPIRE - Arkansas Strategic Plan-
ning Initiative for Results and Excellence. This initia-
tive will help ensure that the Department is properly
focused for the future.
We recognize that the health care environment is
changing rapidly and that we cannot do things just
because that is the way we have always done them.
As the public health needs of our communities and
state are evolving, strategic planning helps identify
public health priorities and how to best use limited
resources.
In July, we solicited volunteers to participate in a
year long strategic planning process. Approximately
100 employees from all parts of the state, representing
a cross-section of all personnel classifications, agreed
to participate in the project. At our kickoff meeting in
August, training was provided, and the Situational
Analysis Phase of the process began.
Three teams worked for the next three months to
analyze the current environment:
■^The Internal Assessment Team's assignment was
to assess the Department's internal strengths and weak-
nesses. They identified and evaluated several sub-
systems of the Department — financial, facilities and
operations, human resources, information and com-
munication, and organizational excellence.
*The External Assessment Team concentrated on
identifying the changes outside the Department which
will have a significant impact. Using a variety of data
gathering techniques they identified changes in such
areas as demographics, lifestyles, government, and
technology.
*The Mission/Vision Team's objectives were to
reach consensus on and to generate clear, concise state-
ments of the Department's mission and vision, and to
identify critical success factors necessary for the agency
to be able to accomplish its mission and realize its vi-
sion. They met with employee groups from all over
the state and held brainstorming sessions to gain
broad-based input.
The results of these teams' work was presented in
December. During early 1997, the Steering Committee
will carefully study this information in order to de-
velop strategies to move the Department forward.
Then, an Implementation Team of employees will as-
sist with the development of specific goals and action
plans to implement the strategies throughout the De-
partment.
It is an exciting process for the Department, and I
look forward to working with you as we sharpen our
focus in order to better meet the public health needs
of Arkansas. This effort will build upon a tradition of
service and commitment to protecting and improving
the health of Arkansans, as evidenced by the follow-
ing additional accomplishments in 1996.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Personal Health Services
*Began screening newborns for hearing loss in the
hospital nursery setting. The purpose of the screen-
ings is to provide for early detection of hearing loss
which can affect speech, psycho-social, language and
cognitive development.
^Reduced the number of syphilis cases by more
than 20%. This follows the national trend of declining
case rates.
^Amended the Rules & Regulations Pertaining to
Communicable Disease Control to require the report-
ing of new and emerging diseases to include
Enterhemorragic E Coli 0157-H7, Cryptosporidiosis,
Hantavirus infection. Hepatitis C, and drug resistant
Enterococci and to eliminate reporting requirements
for 13 diseases which are no longer considered highly
contagious and are seldom fatal.
Physicians were also requested to report blood lead
levels over lOmg/dl for patients 14 years old or younger
and levels over 25 mg/dl for patients 15 years old and up.
^Supplied vaccine for post exposure rabies treat-
ment to 170 Arkansans because of exposure to an ani-
mal known or suspected to be rabid.
^Implemented newborn screening for galactosemia
and an enzymimmunoassay quantitative fluorometric
method for testing for newborn phenylalanine.
^Targeted causes of secondary disabilities for pre-
vention efforts. A state strategic plan has been devel-
oped to increase the role of the agency in surveillance
and prevention of secondary disabilities.
^Instituted gen-probe mycobacteria tuberculosis di-
rect amplification technology in the Public Health Labo-
ratory.
^Conducted a pilot study on the prevalence of
chlamydia. Fourteen local health units submitted over
12,000 specimens, of which 7.2% were confirmed to
have chlamydia.
"^Restructured the maternal and infant home visit-
ing program to improve the availability of services.
1,774 infants and their families were served in state
fiscal year 1996.
"^Completed the first full year of offering breast
and cervical cancer screening to women age 50 and
older who met income guidelines. Over 2,000 screen-
ing mammograms and pap smears were provided
during FY96.
Environmental Health Services
"^Intervened in the inactive Vertac Chemical Com-
pany site in Jacksonville, Arkansas, which is contami-
nated with dioxin (2,3,7, 8 tetrachloro dibinzodioxin)
so that the site will be remediated by scrapping off all
contaminated soil to 5 part per billion (ppb) or less of
dioxin. The company originally was going to scrape
soil down to 50 ppb.
"^Assisted ATSDR in conducting a Health Assess-
ment in El Dorado because of citizen complaints that
bromides from the Great Lakes Chemical Company
were adversely affecting the health of the community.
Air monitoring, soil and surface water testing and blood
testing of more than 20 people living around the plant
did not show any abnormal levels or contamination
by bromide.
"^Conducted 5 indoor air quality seminars across
the state for school systems. These were attended by
school officials, board members, nurses, and public
health officials. This was funded by a $30,000 grant
from the U.S. Environmental Protection Agency.
"^Conducted 90 mammography quality inspections
under a U.S. Food and Drug Administration (FDA)
contract.
"^Revised the Rules and Regulations for Control of
Sources of ionizing Radiation. The regulations affect
approximately 270 radioactive material licensees and
2,370 x-ray registrants.
"^Established a system to maintain inventory data
involving the placement of nerve agent antidote kits
in the vicinity of Pine Bluff arsenal for the Chemical
Stockpile Emergency Preparedness Program.
"^Participated in the Arkansas Chemical Stockpile
Emergency Preparedness Programs (CSEPP) Commu-
nity Exercise. The exercise assesses community medi-
cal capabilities in response to a chemical event in the
area surrounding the Pine Bluff Arsenal. Work is on-
going with the State Office of Emergency Services (OES)
to develop an emergency medical support program.
"^Entered into a five year cooperative agreement
with the Agency for Toxic Substances and Disease
Registry (ATSDR) to conduct necessary public health
assessments, health consultations, health studies, com-
munity involvement and health education activities
regarding superfund sites, CERCLIS sites, and mer-
cury in fish along the Saline River Basin.
"^Completed a pilot study in conjunction with the
University of Arkansas at Pine Bluff to assess the en-
vironmental health issues in the Assessment Protocol
for Excellence in Public Health (APEX-EH) planning
system. The pilot project focused on compiling pri-
mary and secondary data on potential environmental
health threats and the level of local concern about en-
vironmental health issues.
Technical and Support Services
"^Updated and modified the blood lead database.
The data base collects information from clinics, pri-
vate physicians, hospitals and commercial laborato-
ries on children and individuals who have been iden-
tified with high blood lead levels.
"^Conducted satellite video conferences on a vari-
ety of topics:
Nutritio7i: Making a Difference in Schools for nutri-
tionists, home economists, health educators, school
food service personnel, physical education faculty, and
business and community leaders.
Volume 93, Number 11 - April 1997
541
Getting Kids Moving: Nutrition for Fitness and Sports
for over 400 participants interested in the nutrition
needs and nutrition problems encountered with chil-
dren involved in both organized and individual fit-
ness/sports programs.
Domestic Violence: Breaking the Cycle. After the two
hour teleconference a panel of local and state experts
responded to questions from on-site participants.
Surveillance of Vaccine Preventable Diseases, a three
hour course for physicians and nurses.
Epidemiology and Prevention of Vaccine Preventable
Diseases, two 12 hour courses presented to physicians
and nurses. Continuing Education Units and Medical
Education Units were offered.
Mmunization Update for public health profession-
als, physicians, and nurses.
^Targeted Hispanic women in the Campaign for
Healthier Babies by developing ads, posters, and
Happy Birthday Baby Books in Spanish.
^Developed a Cultural Diversity Training Module
and trained public health personnel in Arkansas and
Alabama.
^Sponsored the first beginners course in cancer
registry operations for hospitals across the state Regis-
trars were introduced to the cancer patient data man-
agement system.
’^Assisted 108 businesses and civic groups in pro-
viding educational and promotional materials to guide
in the development of drug-free workplace programs
through the "Drugs Don't Work" campaign.
^Implemented, with the University of Arkansas at
Pine Bluff, the Delta Assessment Center for Drug and
Alcohol Prevention The Center will provide technical
assistance and program monitoring to community-
based alcohol, tobacco and other prevention programs
in the following Arkansas Delta counties Arkansas,
Ashley, Chicot, Crittenden, Cross, Desha, Drew,
Jefferson, Lee, Lincoln, Mississippi, Monroe, Phillips,
Poinsett, St. Francis, and Woodruff.
“^Coordinated the statewide Arkansas observance
of the annual national "Treatment Works!" campaign
to promote alcohol and drug abuse treatment.
“^Implemented "The State Health Data Clearing
House Act" of 1995. The Act authorizes the Depart-
ment of Health to establish an information base for
patients, health professionals and hospitals in order
to improve the usage of health care services.
“^Initiated the Water Wizard Education Program.
The program trains and equips volunteers and helps
them develop science presentations about the magic
of water treatment. Over $25,000 worth of equipment
was distributed to twelve sites across the state.
“^Conducted several workshops:
Nutrition Assessment Workshop for nurses, nutrition-
ists, and home economists at WIC statewide Partners
in Growth Conference. The program provided an up-
date on the anthropometric, biochemical, clinical, diet
542
and socio-economic components of nutrition assess-
ment.
Nutrition: A Vital Link in Health Services for a Special
Population for nurses and nutritionists from Iowa, Okla-
homa, Arkansas, and Missouri at the Nutrition and
Mental Health Issues Conference. The program pro-
vided an update on the best practice for the nutritional
management of gestational diabetes.
Food Safety Workshop, with the U.S. Food and Drug
Administration and the Educational Foundation of the
National Restaurant Association, for sanitarians and
representatives from the food industry, including res-
taurant managers and other state agencies. The two
day course focused on identifying critical areas of food
service that must be properly monitored in order to
avoid foodborne illnesses.
Toxic Chemical Training Course for Hospital Personnel,
in conjunction with the Office of Emergency Services,
for physicians, nurses, paramedics and hospital safety
officers from 19 hospitals and two ambulance services.
Participants were taught to recognize the clinical signs
and symptoms of nerve and mustard agent exposure
and appropriate therapeutic interventions for treating
these patients in the hospital emergency department,
decontamination procedures, personal protective
equipment and emergency department planning con-
siderations.
“^Conducted a survey of how other public health
laboratories perform, interpret and report HIV results.
The findings were presented at the National Retroviral
Testing Symposium.
Collaboration/Partnerships
“^Updated Operation Kid Care brochures, speak-
ers kits and "Checkup Checkbooks." Arkansas' First
Lady Janet Huckabee was named as the honorary chair.
Sponsors of Operation KidCare included Arkansas Blue
Cross and Blue Shield, Arkansas Children's Hospital,
Arkansas Department of Health, Arkansas Department
of Human Services, Arkansas Methodist Hospital in
Paragould, Northwest Medical Center in Springdale,
St. Bernards Regional Medical Center in Jonesboro,
St. Mary's Hospital in Rogers, St. Vincent Infirmary
Medical Center, and Washington Regional Medical
Center in Fayetteville.
“^Unveiled a map at the State Capitol showing each
county which has attained its goal of immunizing at
least 90% of children by the age of two. As of Decem-
ber 1996, 40 of the 75 counties had achieved this mile-
stone. This project is in partnership with Arkansas'
Shots for Tots.
“^Collaborated with the National Kidney Founda-
tion of Arkansas to develop a program to provide high
blood pressure education and screening to residents
of Pulaski and Lonoke counties. The program goal is
to reduce the incidence of kidney disease, heart disease,
and stroke among minority communities in these counties.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
’^Collaborated with the Arkansas Health Care Ac-
cess Foundation to provide access to voluntary medi-
cal services for women needing diagnostic follow-up
who were identified through the Breast and Cervical
Cancer Control Program. Over 190 women have re-
ceived services.
"^Developed a partnership with Essential Spanish
Seminars to teach Spanish classes to Department em-
ployees. The course lasts eight weeks and is free to
employees on a "first come, first served" basis.
“^Expanded the 5-A-Day for Better Health Coali-
tion, both in active membership and activities. Partici-
pating coalition agencies include Cooperative Exten-
sion Service, AARP, Baptist Health, UAMS, Depart-
ment of Education, Arkansas Radio Network, Conway
Regional Fitness Center, Arkansas Dietetic Association,
and individuals including Willie Oates.
^Developed the Referral, Assessment and Place-
ment (RAP) System to assist in the placement of court
committed individuals into substance abuse treatment
within Pulaski County. Two substance abuse counse-
lors working with the Pulaski County Probate Court
and central Arkansas substance abuse treatment pro-
grams evaluate patients and coordinate placements to
ensure a smooth transition into treatment.
"^Implemented the Regional Alcohol and Drug
Detoxification (RADD) Program to provide detoxifica-
tion services to substance abusing individuals in thir-
teen (13) different regions of the state. This was a col-
laborative effort between the Bureau of Alcohol and
Drug Abuse Prevention, its funded treatment provid-
ers, local mental health centers and Ouachita County
Medical Center. The RADD Program services increased
detoxification services to the citizens of the state of
Arkansas by 72% in the first six (6) months of operation.
“^Contracted with the Arkansas Department of
Human Services to provide Medicaid Outreach and
Education services to Medicaid recipients and Medic-
aid primary care providers. Services include 24-hour
access to answers concerning issues related to the
Medicaid Primary Care Case Management Program.
^Served as a partner in the Delta Health Education
Partnership Project. This is a multi-state consortium
funded by the Robert Wood Johnson Foundation to
plan community-based educational programs for pri-
mary health care providers within the lower Missis-
sippi Delta region.
“^Worked with Cooperative Extension Service Home
Economists from the Southwest and Southeast dis-
tricts to educate communities in south Arkansas re-
garding mercury in fish. Developed a coloring book
for children from grades 1-3 to use for raising the aware-
ness of children and their parents regarding this issue.
Special Recognition
“^Recognized for excellence in early enrollment of
pregnant women in the WIC Program. Local health
unit staff are diligent in the enrollment of pregnant
women, coupled with a toll-free information line and
the availability of the Happy Birthday Baby Book
through the Campaign for Healthier Babies, has lead
to an increased number of women being served ear-
lier in their pregnancy.
“^Selected for inclusion in the National Database of
Exemplary Child Abuse Prevention Programs. The
A-Plus (Adolescent Parents Learning Useful Skills)
Program is a Washington County based pregnant and
parenting teen support program which has been in
existence since 1988.
“^Won the 1996 National Gold Award for Excellence
in Public Health Communication from the National
Public Health Information Coalition for the press kit
developed for 5-A-Day Week.
“^Worked with state and local groups to expand
the Smoke Detector Program, resulting in it being
named a national model by the National Center for
Injury Prevention and Control of CDC.
“^Received a national award for the Keep Illegal
Cigarettes from Kids (KICK) campaign. The campaign
received the 1996 Vision Award from the Association
of State and Territorial Health Officials for excellence
in public health through innovation. KICK also received
two Bronze Quill Awards from the International As-
sociation of Business Communicators.
“^Received the Healthy Mothers, Healthy Babies
National Achievement Award for Outreach to
Hard-to-Reach Populations for the Delta Community
Integrated Service System project.
“^Was presented the prestigious "Telly" award for
the Campaign for Healthier Babies television commer-
cial, "Don't Be A User," which pointed out the dan-
gers of drug abuse by pregnant women.
“^Received the Commissioner's Special Citation
from the Food and Drug Administration's Center for
Devices and Radiological Health for outstanding col-
laboration in working with FDA on inspecting mam-
mography facilities.
“^Received the Category II Quality Commitment
Award in recognition of employee commitment to total
quality management principles in Management Area VI.
“^Awarded two Silver awards by the National Pub-
lic Health Information Coalition for Excellence in Com-
munication for a radio public service announcement
and a feature release.
Grants and Funding
“^Entered into a five year cooperative agreement
with the Agency for Toxic Substances and Disease
Registry (ATSDR) for capacity building in environmen-
tal health. The Arkansas Department of Health will be
awarded $219,876 annually to expand environmental
health activities.
“^Received a five year, $540,000 grant from the Centers
for Disease Control and Prevention to implement a
Volume 93, Number 11 - April 1997
543
Pregnancy Risk Assessment Monitoring System
(PRAMS). Information will be collected concerning a
mother's experience with the health care system dur-
ing pregnancy and delivery, as well as postpartum
care for both the mother and infant. Information will
also be collected on maternal behaviors and experi-
ences which might have influenced the outcome of
the pregnancy and the health of the infant.
*A warded 20 rural health services revolving grants
to communities to enhance their local healthier deliv-
ery systems.
*A warded grants to 25 rural physicians who are
participating in the Rural Physicians Incentive Program.
^Approved funding through the State Health Build-
ing and Local Grant Trust Fund for the following:
$450,000 for construction of a new local health unit in
Marion County - Yellville; minor grants to Johnson
County - Clarksville, $575; Pope County - Russellville,
$7,589; Pulaski County - Central Unit, $9,874.
^Submitted requests through the Arkansas Eco-
nomic Development Program (AEDP) of the Arkansas
Industrial Development Commission, Community
Assistance Division for construction of new local health
units in Union County - El Dorado, Saline County -
Benton, Poinsett County - Trumann and Woodruff
County - Augusta.
^Received a $5,000 grant from the Department of
Health and Human Services Region VI Office of Mi-
nority Health to support the Arkansas Minority Health
Summit.
^Initiated plans to develop a State Revolving Fund
(SRF) for Drinking Water in Arkansas. The Department
is establishing priorities for the program and will main-
tain oversight. The initial authorization could provide
up to $12,500,000 to Arkansas as an SRF capitalization
grant. The majority of the funds will be available to
Arkansas water systems as low-interest loans for capi-
tal improvements to assure their compliance with the
Safe Drinking Water Act.
“^Awarded 24 community-based youth violence
prevention grants for a total of $989,586, through the
Common Ground Program for Arkansas Communi-
ties. The program is to "act as a bridge" connecting
and assisting government, communities and citizens
to build a more responsive human, educational, and
economic system where children and families can
thrive.
^Provided treatment service grants for dual diag-
nosis clients (clients with a substance abuse and psy-
chiatric problem) to encourage substance abuse treat-
ment services to this underserved population.
*A warded Prevention Service Program grants to
25 community-based non-profit organizations to imple-
ment alcohol, tobacco and other drug abuse preven-
tion activities that target high-risk youth. Four $10,000
grants and 21 $20,000 grants were funded.
544
^Awarded eight Community Coalition grants to
local community groups for planning and implement-
ing alcohol, tobacco and other drug abuse programs.
"^Awarded funding to four local education agen-
cies to provide classroom instruction by a uniformed
law enforcement officer on alcohol, tobacco and other
drug education.
^Awarded four youth conference grants to
community-based non-profit organizations to host al-
cohol, tobacco and other drug education and preven-
tion workshops targeting junior high and senior high
school students.
*A warded nine Delta Initiative Program grants to
provide culturally sensitive alcohol and drug abuse
prevention programs for high risk minority youth who
reside in the Delta region. Programs were funded in
the communities of Augusta, Marvell, Earle, Holly
grove, Marianna, Stuttgart, Pine Bluff, Eudora, and
Dermott.
*A warded mini-grants to 11 local coalitions for to-
bacco control and prevention. The grants are aimed at
reducing youth access to tobacco, reducing exposure
to second-hand smoke in public places, and making
the public aware of the problems associated with tobacco.
“^Received funding from the Maternal and Child
Health Bureau for an epidemiology program in Peri-
natal Health. The program will evaluate the state's
perinatal health status and enhance the analytical ca-
pabilities of the state regarding issues concerned with
infant mortality and low birth weight.
^Received a three-year grant from the U.S. Depart-
ment of Agriculture, Food and Consumer Service, to
develop a methodology for determining local clinic
costs and predicting local costs of providing services
through the Supplemental Nutrition Program for
Women, Infants and Children (WIC).
^Received a grant from the Centers for Disease
Control and Prevention for Diabetes Prevention and
Control. The main components of the grant include
assessment of interventions and capacity building.
^Received funding from the Maternal and Child
Health Bureau to continue the Delta Community Inte-
grated Services System project. This project trains and
uses lay personnel to improve immunization levels and
provide for adequate day care.
*Was awarded a State Systems Development Ini-
tiative grant from the Maternal and Child Health Bu-
reau to establish a statewide planning process for co-
ordination of comprehensive community based health
services and community systems of care for children
and families, including Children with Special Health
Care Needs.
■^Received a two-year contract from the Department
of Human Services to provide Lead Poisoning Educa-
tion. The target audience includes, but is not limited
to children, parents, day care operators, and teachers.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The three counties involved include Union, Phillips
and Pulaski.
What's Ahead
1997 promises to be another exciting year at the
Arkansas Department of Health. We will continue to
develop our strategic plan and will begin to imple-
ment strategic management. We look forward to work-
ing with you to help assure conditions which encour-
age a healthier quality of life for people in the state.
Table 1
Personal Health Services - Selected Statistics
Services
FY96
Maternal and Child
Child Health Patients
39,376
EPSDT Screenings
59,362
Family Planning Patients
74,782
Maternity Patients
17,955
WIC Clients Served
150,370
Communicable Disease Control
AIDS Testing and Counseling
71,580
TB Skin Test
77,403
Immunizations
HIB
108,122
Polio
118,271
DPT
141,606
MMR
77,902
Hep B
104,784
In Home Services
Patient Admissions
23,243
Recovering Patient Visits
541,683
Chronic Patient Visits
84,736
Frail Patient Visits
1,040,059
Hospice Patient Days
37,320
Substance Abuse Treatment
Adults Served
13,186
Adolescents Served
784
Regional Alcohol and Drug
Detoxification (RADD) Patients Served
1,922
Table 2
Services to Protect the Environment and
Health of the General Public - Selected Statistics
Services FY96
Environmental Complaints
Investigations 7,039
Food Service Establishment
Inspections 17,084
Laboratory Samples
Analyses 488,109
Milk and Dairy Farm
Inspections 7,444
Protective Health Codes Licenses
Issued 12,681
Public Swimming Pool
Inspections 3,196
Radiological Equipment
Inspections 676
Septic Tank
Permits 6,304
Water and Wastewater Plans
Reviews 3,173
Arkansas Health Care Access Foundation, Inc.
Joe Colclasure, MD, President
"I wanted to thank everyone involved with this pro-
gram. We had no one else to turn to, and we were in desper-
ate need of doctors and medications. Your program has helped
us through a very difficult time. "
At the Arkansas Health Care Access Foundation,
we receive many thanks from those who have ben-
efited from the help of our volunteers. Through the
combined efforts of many, individuals receive medical
care that otherwise would have been unavailable to
them.
The Arkansas Health Care Access Foundation
(AHCAF) has again seen an increase in interest and
enrollment in the Access to Care program. The De-
partment of Human Services Medicaid Offices as well
as County Health Units continue to act as points of
entry into the referral system.
Currently, there are over 6,400 active applications
in our system. Our numbers grew substantially when
an article was published detailing our program in the
Arkansas Democrat-Gazette in June of last year. We
received an unprecedented number of phone calls, and
our application volume tripled in one month. Only
within the last few months have the calls returned to
our standard levels. Additional publicity was gener-
ously donated by KATV, Channel 7, through a public
service announcement which aired frequently in 1996.
Inquiries increased dramatically each time that an-
nouncement was aired. Approximately $100,000 in air
time has been provided by Channel 7 on behalf of
AHCAF.
The Foundation continues its work of coordinat-
ing with the Arkansas Department of Health's Breast
Volume 93, Number 11 - April 1997
545
and Cervical Cancer Control Program (BCCCP) in assisting
poor, uninsured Arkansas women in obtaining fur-
ther diagnosis and treatment as needed. From No-
vember '95 through January '97, more than 190 women
screened through the BCCCP program have received
donated office visits, evaluation, radiology, pathology,
anesthesiology, oncology, surgery and hospitalization
from AHCAF volunteer professionals. Needless to say,
we are most thankful for you and your caring staff
who have allowed these women access to lifesaving
care that they otherwise might not have received.
The Foundation is also exploring the possibility of
assisting in the establishment of a dental care program
for needy, low-income Arkansans. At press time, a
bill has been signed by Governor Huckabee to estab-
lish the Donated Dental Services program. We have
pledged our help in seeing the program to become a
success.
With an increase in enrollment, we have called on
Arkansas' hospitals to provide services more than ever
before. They have been most supportive and coopera-
tive, and we are grateful for their dedication in pro-
viding a wide variety of in-patient and out-patient ser-
vices. Their willingness to work with AHCAF lends
great support to the physicians treating our referred
patients.
Since July 1, we have processed over 8,000 phone
calls. In a continuing effort to expand the types of ser-
vices to the medically indigent in Arkansas, the Foun-
dation is reaching across health care boundaries by
working in a cooperative effort with other health orga-
nizations in the state. Since last February, we have
made over 795 other referrals for services outside our
program. The Arkansas Health Care Access Founda-
tion boasts over 1,000 physician volunteers, which is
up from 860 in 1989. This entire AHCAF network of
over 1,700 health professionals, consisting of physi-
cians, dentists, pharmacists, podiatrists, hospitals,
home health agencies, the Arkansas Department of
Health, and the Arkansas Department of Human Ser-
vices, has "insured" almost 45,000 needy Arkansans
at an annual cost of approximately $15.00 per year,
per patient.
Special acknowledgment and thanks is owed to
Pfizer, Johnson & Johnson, and SmithKline Beecham
Pharmaceuticals, who continue to make their prod-
ucts available through our program. By providing their
products at no charge to the patient, they have helped
ensure continuity of care. Additionally, they have as-
sisted by donating the printing of our brochures, ap-
plications, and other forms.
In addition to these pharmaceutical companies, we
are currently working with two other well-known
manufacturers to provide two groups of drugs cur-
rently not donated through our program.
Recruitment of volunteers remains a high priority
546
for the Foundation. Medical professionals are recruited
on a regular basis and continue to generously and com-
passionately provide much needed care. Our staff re-
mains active in participating in workshops, in-services
and talk shows to help promote the Foundation's work.
This past year, at each association conference, we pre-
sented an "Outstanding Spirit of Service" award rec-
ognizing a special volunteer in each field. These awards
were made possible by a generous grant from
SmithKline Beecham Pharmaceuticals.
Support from all sectors of the health care com-
munity has proven to be a key to maintaining a suc-
cessful program. Our volunteers continue a commit-
ment to serve those Arkansans who are poor and
medically uninsured. Thank you for making AHCAF
the type of program that has made a difference in many
lives.
If you are interested in knowing more about this
method of providing care to Arkansas' indigent, please
contact one of the physician board members listed be-
low or call 1-800-950-8233.
Joe Colclasure, MD - Little Rock 227-5050
Simmie Armstrong, MD - Pine Bluff 535-6461
Charles Chalfant, MD - Fort Smith 484-7100
Rep. Scott Ferguson, MD - W. Memphis 735-5555
Leslie Anderson, MD - Lonoke 676-5123
Paul Wallick, MD - Monticello 367-6867
Ray Biondo, MD - Sherwood 835-6512
L.J. Patrick Bell, MD - Helena 338-8163
C.E. Ransom, Jr., MD - Searcy 268-5845
Arkansas State Medical Board
Peggy Pryor Cryer, Executive Secretary
The 1996 members and officers of the Arkansas
State Medical Board are as follows: W. Ray Jouett, M.D.,
Chairman; Warren M. Douglas, M.D., Vice-Chairman;
Alonzo Williams, M.D., Secretary; John Currie, Sr.,
Treasurer; J. R. Baker, M.D.; John E. Bell, M.D.; Owen
Clopton, M.D.; Steven Collier, M.D.; Ted J. Feimster;
David C. Jacks, M.D.; C.E. Tommey, M.D.; Rhys Wil-
liams, M.D.; and James Zini, D.O.
The Board met quarterly and addressed com-
plaints, hearings and other pertinent business affect-
ing health care in the State of Arkansas.
The 1996 Licensing Statistics are: Medical Doctors
and Doctors of Osteopathy licensed - 466; Medical
Doctors and Doctors of Osteopathy (total) - 7,514; Medi-
cal Doctors and Doctors of Osteopathy (in state) - 4,707;
Occupational Therapist Licensed - 149; Occupational
Therapist - 639; Occupational Therapist Assistants Li-
censed - 38; Occupational Therapist Assistants - 106;
Physician Trained Assistants - 40; Respiratory Care
Therapist Licensed - 187; Respiratory Care Therapist - 1,059.
Summary of the Board's proceedings for 1996: In-
dividual Complaints and Discussions - 272; Show
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Cause Orders Issued - 22; Suspended License - 12;
License placed on Probation - 15; Monetary Fine - 8;
Physicians requested to appear for further discussion
- 14; Physicians required to notify Board before prac-
ticing in the state - 6; Revoked - 5; Overtreating - 4;
Billed for services not performed - 1; Rights violated -
2; Reviewed for 2nd time - 18.
Nature of Complaints: Quality of care issues - 72;
Communication or doctor/patient conflicts - 40; Emer-
gency room treatment - 2; Alcohol/Drugs - 9; Billing
Discrepancies - 13; Lack of Physician response to pa-
tient - 4; Failure to release medical records - 5; Over-
charging - 3; Sexual Harassment - 4; Actions taken by
other State Boards - 6; Overtesting - 4; Over prescrib-
ing - 11; Practicing/allowed to practice with out a li-
cense - 4.
Public Hearings were held on Regulation #8 and
#10. Regulation #8 was repealed. Regulation #10
changes the fee and licensing requirements of Respi-
ratory Care Therapist.
Financial Report
Assets 1996
Current Assets
Cash $570,756
Certificates of deposit 1,217,283
Accrued interest receivable 15,886
Total Current Assets $1,803,925
Fixed Assets - at cost
Furniture, fixtures and equipment $105,736
Less: accumulated depreciation (64,014)
Net Fixed Assets $41,722
Total Assets $1,845,647
Liabilities and Net Assets
Current Liabilities
Deferred income $85,770
Accrued unused vacation pay 17,815
Total Current Liabilities $103,585
Net Assets, Unrestricted $1,742,062
Total Liabilities and Net Assets $1,845,647
Regulations Passed by the Board and/or Amended
Regulation 17 - Continuing Medical Education
Passed 9/96
A. Pursuant to Ark. Code Ann. 17-80-104, each per-
son holding an active license to practice medicine in
the State of Arkansas shall complete twenty (20) credit
hours per year of continuing medical education. One
hour of credit will be allowed for each clock hour of
participation and approved continuing education ac-
tivities, unless otherwise designated in Subsection B
below.
B. Approved continuing medical education activities
include the following:
1. Internship, residency or fellowship in a teach-
ing institution approved by the Accreditation Counsel
for Graduate Medical Education (ACGME) or programs
approved by the American Osteopathic Association
Council on Postdoctoral Training or the American Medi-
cal Association or the Association of American Medi-
cal Colleges or the American Osteopathic Association.
One credit hour may be claimed for each full day of
training. No other credit may be claimed during the
time a physician is in full-time training in an accred-
ited program. Less than full-time study may be claimed
on a pro-rata basis.
2. Education for an advanced degree in a medical
or medically related field in a teaching institution ap-
proved by the American Medical Association or the
Association of American Medical Colleges or the Ameri-
can Osteopathic Association. One credit hour may be
claimed for each full day of study. Less than full-time
study may be claimed on a pro-rata basis.
3. Full-time research in a teaching institution ap-
proved by the Liaison Committee on Medical Educa-
tion (LCME) or the American Osteopathic Association
Bureau of Professional Education or the American
Medical Association or the Association of American
Medical Colleges or the American Osteopathic Asso-
ciation. One credit hour may be claimed for each full
day of research. Less than full-time study may be
claimed on a pro-rata basis.
4. Activities designated as Category 1 or 2 by an
organization accredited by the Accreditation Council
on Continuing Medical Education or a state medical
society or be explicitly approved for Category 1 or 2 by
American Medical Association, or the Arkansas State
Medical Board, or by the Council on Continuing Medi-
cal Education of the American Osteopathic Associa-
tion. Activities designated as prescribed hours by the
American Academy of Family Physicians.
5. Medical education programs may also be claimed
for credit if said medical education programs have not
been designated for specific categories referred to in
Number 4 above, and are designed to provide neces-
sary understanding of current developments, skills,
procedures or treatment related to the practice of medicine.
6. Serving as an instructor of medical students,
house staff, other physicians or allied health profes-
sionals from a hospital or institution with a formal train-
ing program, where the instruction activities are such
as will provide the licentiate with necessary under-
standing of current developments, skills, procedures
or treatment related to the practice of medicine.
7. Publication or presentation of a medical paper,
report, book, that is authored and published, and deals
with current developments, skills, procedures or treat-
ment related to the practice of medicine. Credits may
be claimed only once for materials, presented. Credits
Volume 93, Number 11 - April 1997
547
may be claimed as of the date of the publication or
presentation. One credit hour may be reported per
hour of preparation, writing and/or presentation.
8. Credit hours may be earned for any of the fol-
lowing activities which provide necessary understand-
ing of current developments, skills, procedures or treat-
ment related to the practice of medicine: (a) comple-
tion of a medical education program based on self-
instruction which utilized videotapes, audiotapes,
films, filmstrips, slides, radio broadcasts and comput-
ers; (b) independent reading of scientific journals and
books; (c) preparation for specialty Board certification
or recertification examinations; (d) participation on a
staff committee or quality of care and/or utilization
review in a hospital or institution or government
agency.
C. If a person holding an active license to practice
medicine in this State fails to meet the foregoing re-
quirements because of illness, military service, medi-
cal or religious missionary activity, residence in a for-
eign country, or other extenuating circumstances, the
Board upon appropriate written application may grant
an extension of time to complete same on an indi-
vidual basis.
D. Each year, with the application for renewal of a
active license to practice medicine in this State, the
Board will include a form which requires the person
holding the license to certify by signature, under pen-
alty of perjury, that he or she has met the stipulated
continuing medical education requirements. In addi-
tion, the Board may randomly require physicians sub-
mitting such a certification to demonstrate, prior to
renewal of license, satisfaction of the continuing medi-
cal education requirements stated in his or her certifi-
cation. A copy of an American Medical Association
Physician's Recognition Aware (AMA PRA) certificate
awarded to the physician and covering the reporting
period shall be bona fide evidence of meeting the re-
quirements of the Arkansas State Medical Board. A
copy of the American Osteopathic Association or the
State Osteopathic Association certificate of continuing
medical education completion or the American Osteo-
pathic Association's individual activity report shall be
bona fide evidence of meeting the requirements of the
Arkansas State Medical Board.
E. Continuing medical education records must be
kept by the licensee in an orderly manner. All records
relative to continuing medical education must be main-
tained by the licensee for at least three (3) years from
the end of the reporting period. The records or copies
of the forms must be provided or made available to
the Arkansas State Medical Board upon request.
F. Failure to complete continuing medical education
hours as required or failure to be able to produce
records reflecting that one has completed the required
minimum continuing medical education hours shall
be a violation of the Medical Practice Act and may
result in the licensee having his license suspended and/
or revoked.
548
G. A person may apply to the Board for a waiver
from the continuing medical education requirements
stated herein if he has a license to practice medicine in
the State of Arkansas, is willing to enter a sworn state-
ment to the Board that he is retiring from the active
practice of medicine and will not practice medicine in
the future, he may present his application to the Board
for said exemption.
Regulation 18 - For Schedule for Centralized Verifi-
cation Service - Passed 06196
Pursuant to Ark. Code Ann. 17-95-105-(c)(6) provides
that the Board may charge credentialing organizations
fee for the use of credentialing services.
A. Initial fee to be charged to accrediting organiza-
tions per number of physicians to be credentialed:
Number of Physicians Fee
0-199 $100.00
200-499 $250.00
500 and above $400.00
B. Annual renewal fee for all accrediting organiza-
tions utilizing this centralized verification services:
$50.00 per year
C. Fees for individual information requests:
Service
Initial
Licensure
In State
Out of State
Information
$50.00
$75.00
Renewal
Information
$20.00
$35.00
Detailed
Verifications
$15.00
$20.00
Regulation 19 - Pain Management Programs -
Passed 12/96
A. Physicians opera ring a pain management program
for specific syndromes... that is headache, low back
pain, pain associated with malignancies, or temporo-
mandibular joint dysfunctions... are expected to meet
the standards set forth in this section or in fact be in
violation of the Medical Practices Act by exhibiting
gross negligence or ignorant malpractice.
B. Definitions:
1. Chronic Pain Syndrome: Any set of verbal and/
or non-verbal behaviors that: (1) involves the complaint
of enduring pain, (2) differs significantly from a
person's premorbid status, (3) has not responded to
previous appropriate medical and/or surgical treatment,
and (4) interferes with a person's physical, psycho-
logical and social and/or vocational functioning.
2. Chronic Pain Management Program provides
coordinated, goal-oriented, interdisciplinary team ser-
vices to reduce pain, improving functioning, and decrease
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
the dependence on the health care system of persons
with chronic pain syndrome.
C. The following standards apply to both inpatient
and outpatient programs and the physician should
conform to the same.
1. There should be medical supervision of physi-
cian prescribed services.
2. A licensee should obtain a history and conduct
a physical examination prior to or immediately follow-
ing admission of a person to the Chronic Pain Man-
agement Program.
3. At the time of admission to the program, the
patient and the physician should enter into a written
contract stating the following:
a. The presenting problems of the person served.
b. The goals and expected benefits of admission.
c. The initial estimated time frame for goal
accomplishment.
d. Services needed.
D. In order to provide a safe pain program, the scope
and intensity of medical services should relate to the
medical care needs of the person served. The treating
physician of the patient should be available for medi-
cal services. Services for the patient in a Chronic Pain
Management Program can be provided by a coordi-
nated interdisciplinary team of professionals other than
physicians. The members of the core team, though
each may not serve every person should include:
a. A Physician.
b. A clinical psychologist or psychiatrist.
c. An occupational therapist.
d. A physical therapist.
e. A rehabilitation nurse.
E. A physician managing a Chronic Pain Manage-
ment Program to a patient should meet the following
criteria:
1. Three years experience in the interdisciplinary
management of persons with chronic pain.
2. Participation in active education on pain man-
agement at a local or national level.
3. Board certification in a medical specialty or
completion of training sufficient to qualify for exami-
nations by members of the American Board of Medical
Specialities.
4. Two years experience in the medical direction of
an interdisciplinary Chronic Pain Program or at least
six (6) months of pain fellowship in an interdiscipli-
nary Chronic Pain Program.
The Physician must have completed and maintained
at least one (11 of the following:
5. Attendance at one (1) meeting per year of a re-
gional and national pain society.
6. Presentation of an abstract to a regional national
pain society.
7. Publication on a pain topic in a peer review journal.
8. Membership in a pain society at a regional or
national level.
A Definite Plus In
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[ I n s \ li G ■
(501) 224-1 131 • 650 S. Shackleford, Suite 400, Little Rock, AR 72211
Volume 93, Number 11 - April 1997
549
“Getting Started in Medical Practice”
Making the Right Choices
Young Physicians Seminar
IN CONJUCTION WITH THE
Arkansas Medical Society’s 1997 annual Session
Arlington Hotel, Hot Springs, Arkansas
May 1, 1997
1:00-3:30 P.M.
A PRACTICE MANAGEMENT WORKSHOP
FOR PHYSICIANS WHO PLAN TO
• DEAL WITH HMOS, IPAS, ETC.
• JOIN A PARTNERSHIP OR GROUP PRACTICE
• SEEK AN EMPLOYMENT CONTRACT
• GO SOLO
Practice Alternatives
A broad range of practice possibilities are open. We will
examine the options and cover the essential points of
each alternative in order to make rational decisions.
• Solo practice - advantages and disadvantages
• The pro and cons of group practice
• Ownership options - partnerships vs. professional
corporations
• Salary and income distribution formulas
• Expense-sharing associations
Negotiations
Everything can be negotiated before a deal is put
together. Almost nothing is negotiable after the deal is
signed. Avoid critical errors and develop arrangements
designed for long term, mutual success.
• What should be in your employment agreement
• Strategies for successful group practice agreements
• Opportunities and pitfalls
• Buying into a practice
Financial Considerations
Learn the business side of medical practice. Find our
how patients and insurers pay your practice. What
collection techniques are sensitive to patient needs, yet
produce maximum results?
• How patients pay for their services
• Understanding good collections policies and
procedures
• How to deal with health insurers
• How to measure the financial health of your practice
Dealing with Managed Care
Financial arrangements with third party payers have
changed how physicians provide services. Find out
exactly how managed care works and how it may affect
practice decisions.
• Understanding HMOs, PPOs and IPAs
• How managed care affects revenues and patient
management
• Fee-for-service vs. capitation - trends and issues
Continuing Medical Education Credit
St. Joseph’s Regional Health Center is accredited by the
Arkansas Medical Society to sponsor continuing medical
education for physicians. St. Joseph’s Regional Health
Center designates this continuing medical education
activity for 2.5 credit hours of Category I of the
Physician’s Recognition Award of the American Medical
Association.
________________ ________________________________
Registration Form
Complete and return with your payment to; Arkansas Medical Society, P. O. Box 55088, Little Rock, Arkansas 72215-5088
Registration Fee: Pre-paid: $10 Member Onsite: $20 Member
$15 Non-member $25 Non-member
Refunds will be given if cancellation notice is received three days prior to the seminar.
1997 MED-PAC Contributors
(As of February 28, 1997)
Arkansas County
Hoy B. Speer, Jr.
Marolyn N. Speer
Ashley County
James Rankin
Baxter County
Daniel P. Chock
Stacey M. Johnson
Thomas E. Knox
David T. Sward
Benton County
Rodger Dickinson
Richard S. Rodkin
Jeffrey Tate
Boone County
Carlton L. Chambers
Sue Chambers
James Crider
Charles A. Ledbetter
Don R. Vo well
Columbia County
Franklin D. Roberts
Conway County
Keith M. Lipsmeyer
Craighead/Poinsett Covmties
Glenn E. Dickson
Connie Hiers
Crawford County
Charles Jennings
Crittenden County
G. Edward Bryant
Steven Gubin
Jacinto Hernandez
Bertram D. Kaplan
Samuel G. Meredith
Julio Ruiz
Dallas County
Don G. Howard
Desha County
Peter Go
Faulkner County
Phillip Stone
Garland County
Robert V. Borg
Jesus A. Plaza
Greene/Clay Counties
Roger Cagle
Marion P. Hazzard
Clarence Kemp
J. Larry Lawson
C. Mack Shotts, Jr.
Dwight Williams
Ronald Yamada
Independence County
John R. Baker
Lloyd G. Bess
Sarah Hays
Edward Jones
John S. Lambert
Lackey G. Moody
William J. Waldrip, III
Jackson County
Jabez Jackson
Jefferson County
Omar Atiq
Keith G. Bennett
Charles Clark
Robert Gullett
Johnson County
Ben Kriesel
Miller County
Carey Alkire
Mississippi County
Eldon Fairley
Ouachita County
William D. Dedman
Robert B. Forward
Robert L. Parkman
Phillips County
Kanaka Vasudevan
Parthasarathy Vasudevan
Pope County
Jody Callaway
William W. Galloway
Ted Honghiran
James M. Kolb, Jr.
Douglas H. Lowrey
Pulaski County
Glen Baker
Beverly Beadle
James Billie
Mrs. James W. Campbell
I. L. Carlton
Carol Chappell
R. Lev/is Crow
Thomas L. Eans
Rex M. Easter
Billy E/ans
T. Stuart Harris
John E. Hearnsberger
William F. Hefley
Anthony Johnson
William N. Jones
F. Richard Jordan
R. A. Jordan
Reed Kilgore
Mr. Ken LaMastus
Marvin Leibovich
James S. Mulhollan
Bruce E. Murphy
Jeanne Murphy
Richard A. Nix
Robert A. Porter, Jr.
Carl J. Raque
J. F. Redman
Thomas Rooney
John G. Slater
Jan R. Sullivan
S. Berry Thompson, Jr.
Bill L. Tranum
Edward R. Weber
Michael Weber
John Yocum
Sebastian County
Roger N. Bise
Paul L. Raby
John R. Swicegood
Tri-County
Jim Bozeman
Michael Moody
Union County
Wayne G. Elliott
Walter J. Giller
Bradley Harbin
Mrs. Bradley Harbin
Diana Jucas
Minna Ulmer
Washington County
Jerald Bays
Paul L. Harris
Anthony N. Hui
William C. Mills
Cyril A. Raben
Norman I. Snyder
Robert Tomlinson
White County
David C. Covey
Daniel Davidson
Stephen Lefler
Robert D. Lowery
Volume 93, Number 11 - April 1997
551
1996 MED-PAC Contributors
(As of February 29, 1996)
Arkansas County
Stan W. Burleson
Noble B. Daniel
John M. Hestir
Hoy B. Speer, Jr.
Marolyn N. Speer
Dennis B. Yelvington
Baxter County
Monty Barker
Yoland Condrey
Philip Hardin
Stacey M. Johnson
Thomas E. Knox
Paul Neis
Bruce Robbins
Ben N. Saltzman
David T. Sward
John S. Terkeurst
Joe M. Tullis
Benton County
Alfred Addington
David Halinski
Karen Lanier
Loyd Nugent
Dean Papageorge
John Pappas
Michael Platt
Ralph Ritz
Richard S. Rodkin
Jeffrey Tate
Boone County
Thomas E. Bell
Carlton L. Chambers
Sue Chambers
James Crider
John Hope
Robert Langston
Mrs. Robert Langston
Charles A. Ledbetter
Don R. Vowell
Bradley County
Kerry Pennington
Carroll County
Oliver Wallace
Chicot County
John P. Burge
Clark County
John Elkins
Noland Hagood
Mark Jansen
Columbia County
John E. Alexander, Jr.
Franklin D. Roberts
Craighead/Poinsett Counties
James A. Ameika
Terence P. Braden
Timothy Dow
Charles Dunn
Connie Hiers
John Johnson
James Rogers
Albert H. Rusher
Joe H. Stallings, Jr.
Mrs. Joe H. Stallings, Jr.
Don B. Vollman, Jr.
Joe T. Wilson
Robert Yates
Crawford County
Cecilia Concepcion
Holly Heaver
Charles Jennings
R. Wendell Ross
Michael Westbrook
Crittenden County
G. Edward Bryant
Scott Ferguson
Jacinto Hernandez
Bertram D. Kaplan
James Miller
Trent Pierce
Julio Ruiz
Steve P. Schoettle
Mrs. Steve P. Schoettle
Bedford Smith
Cross County
Ronald Ganelli
Dallas County
Don G. Howard
Desha County
Peter Go
Drew County
Paul A. Wallick
Harold F. Wilson
Faulkner County
Mitchell Collins
John Dobbs
Carole Jackson
Paul McChristian
Gary Wright
Franklin County
David L. Gibbons
Garland County
James Braun
John Dodson
Richard W. Dunn
Allan C. Gocio
James E. Griffin
Jeffrey Herrold
Robert W. Kleinhenz
Jana Martin
Robert McCrary
Jesus A. Plaza
Brenda Powell
Mr. Fess Powell
Eugene Shelby
John Simpson
Gary D. Slaton
James Slezak
J. Wayne Smith
Dow B. Stough, IV
Tom Wallace
Philip A. Woodward
Greene/Clay Counties
J. Darrell Bonner
Roger Cagle
R. Lowell Hardcastle
Marion P. Hazzard
George Hobby
Clarence Kemp
J. Larry Lawson
Jimmy Morrison
John R. Sellars
C. Mack Shotts, Jr.
Vern Ann Shotts
Norman E. Smith
Dwight Williams
Hot Spring County
L. B. Brashears
Howard County
Joe King
Independence County
James D. Allen
John R. Baker
Lloyd G. Bess
Sarah Hays
Jay Jeffrey
Edward Jones
Dennis Luter
Charles McClain
Lackey G. Moody
Fredric J. Sloan
William J. Waldrip, III
Jackson County
Jabez Jackson
Jack Young
Jefferson County
Calvin Bracy
James C. Campbell
Charles Clark
John Crenshaw
Robert Gullett
Shafqat Hussain
David C. Jacks
Lloyd G. Langston
Ralph E. Ligon
David A. Lupo
John O. Lytle
Charles Mabry
Mike S. McFarland
Adil Mohyuddin
Reynaldo Mulingtapang
Ruston Pierce
James Pollard
Anna T. Redman
Robert L. Ross
Aubrey M. Worrell
Lawrence County
Joe Hughes
Ted S. Lancaster
Sebastian Spades
Lee County
Leon Waddy
Lonoke County
B. E. Holmes
Miller County
Rodney Chandler
Larry Peebles
Joseph R. Robbins
Jerry Stringfellow
Mitchell Young
Mississippi County
Ziad Eskandar
Eldon Fairley
Joe V. Jones
Merrill J. Osborne
Brewer Rhodes
John S. Williams
Ouachita County
William D. Dedman
Robert B. Forward
Robert L. Parkman
Phillips County
Francis M. Patton
Parthasarathy Vasudevan
Polk County
David Brown
552
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
1996 MED-PAC Contributors
(As of February 29, 1996)
Pope County
Nathan Austin
Kevin Beavers
Michael Bell
Dennis Berner
Joe B. Grumpier, Jr.
William W. (Calloway
Ted Honghiran
James M. Kolb, Jr.
Mrs. James M. Kolb, Jr.
Frank Lawrence
Douglas H. Lowrey
David S. Murphy
Don C. Riley
Sergio Soto
Darrell Speed
Gerald A. Stolz
Pulaski County
James R. Adametz
Phillip R. Alston
Roger Anderson
Glen Baker
David L. Barclay
C. Lowry Barnes
Barry D. Baskin
Rex H. Bell
Robert L. Berry
David W. Bevans
Michael Bierle
James Billie
William B. Bishop
Mrs. William B. Bishop
John R. Brineman
Randel Brown
Joseph K. Buchman
Anthony Bucolo
Kelsy J. Caplinger
Helen Casteel
Sandra E. Chai
Harold H. Chakales
J. Roger Clark
Joe B. Colclasure
R. Lewis Crow
S. Killeen Deslauriers
D. Bud Dickson
Warren M. Douglas
Thomas L. Eans
Rex M. Easter
Jim English
Ernest Ferris
Debra Fiser
Martin Fiser
William Fiser
Eric Fraser
Anthony R. Giglia
Jim G. Gilbert
William E. Golden
Karen Grant
Volume 93, Number 11
C. Don Greenway
A. David Hall
Gregory S. Hall
James Harrell
Richard Hayes
H. Graves Hearnsberger
John E. Hearnsberger
William F. Hefley
Marcia L. Hixson
Richard W. Houk
Randal F. Hundley
Anthony Johnson
Dianne Johnson
M. Bruce Johnson
Mrs. William Jones
William N. Jones
F. Richard Jordan
R. A. Jordan
John W. Joyce
Reed Kilgore
Michael F. Knox
David Kolb
Gregory Krulin
Mr. Ken LaMastus
Jay M. Lipke
Charles W. Logan
Frank H. Ma
Stephen K. Magie
R. Jerry Mann
Stephen R. Marks
Kenneth A. Martin
Peter M. Marvin
Robert McGrew
J. Malcolm Moore
Debra F. Morrison
James S. Mulhollan
Bruce E. Murphy
Jeanne Murphy
Randolph Murphy
Joseph A. Norton
J. Mayne Parker
Clifton L. Parnell
William Paul
Robert A. Porter, Jr.
Robert C. Power
Robert E. Powers
Carl J. Raque
John Redman
Robert Rice
Robert Ritchie
Charles H. Rodgers
F. Hampton Roy
E. H. Saer
Scott M. Schlesinger
Jan W. Scruggs
Kris Shewmake
John P. Shock
John G. Slater
Jack Sternberg
Doug Stokes
Alan R. Storeygard
J. Samir Sulieman
Jan R. Sullivan
David R. Taylor
Jerry L. Thomas
Mrs. Jerry Thomas
Kathleen Thompsen Hall
S. Berry Thompson, Jr.
Bill L. Tranum
Thomas M. Ward
James R. Weber
Ronald N. Williams
John L. Wilson
Thomas H. Wortham
Paul E. Wylie
Terry Yamauchi
Mohammad Yaseen
John Yocum
Saline County
Ralph Cash
J. Shelby Duncan
James M. Eaton
Edward Hill
Joe L. Martindale
William Thomas
Kirk Watson
Searcy County
Charles D. Daniel
Sebastian County
Mike Berumen
Ronald Bordeaux
Deland Burks
D. Bruce Glover
Derya Hazar
Peter J. Irwin
Greg Jones
Eduardo Mondesert
Steve B. Nelson
Kevin C. Phillips
Taylor A. Prewitt
Mrs. Taylor Prewitt
Paul L. Raby
Stephen Seffense
John R. Swicegood
Mark Teeter
Paul I. Wills
Robert Wilson
Munir M. Zufari
St. Francis County
James P. DeRossitt
Frank Schwartz
Tri-County
Jim Bozeman
Andy Davidson
Michael Moody
Mrs. Michael Moody
Union County
Gary L. Bevill
Matthew D. Callaway
Kenneth R. Duzan
Wayne G. Elliott
Walter J. Giller
Diana Jucas
Gurprem S. Kang
Robert C. Tommey
Minna Ulmer
Srini Vasan
Larkin M. Wilson
Washington County
James A. Arnold
Jerald Bays
Craig Brown
David L. Brown
James F. Cherry
David A. Davis
Ted J. Fish
Ben Hall
Paul L. Harris
Walter D. Harris
Peter Heinzelmann
Anthony N. Hui
K. Marty Hurlbut
C. R. Magness
F. Allan Martin
J. E. McDonald
Mrs. J. E. McDonald
William McGowan
William R. McNair
William C. Mills
James Moore
Mike Morse
Mrs. Mike Morse
Sherry Owens
Danny Proffitt
Cyril A. Raben
Earl B. Riddick
Kenneth Rosenzweig
Norman I. Snyder
Wendell W. Weed
Edwin Whiteside
White County
Daniel Davidson
John C. Henderson
J. Garrett Kinley
Robert D. Lowery
Yell County
Thomas Hejna
- April 1997
553
Memorials
Members of the Arkansas Medical Society and Alliance who have died this past year will
be remembered during the opening House of Delegates beginning at 5:00 p.m., Thursday,
May 1, 1997, at the Arlington Hotel in Hot Springs. Members to be honored are:
Society Members:
William W. Abbott, M.D., Little Rock
James D. Armstrong, M.D., Ashdown
Robert Benafield, M.D., Conway
Eaton W. Bennett, M.D., Little Rock
Robert S. Bryles, M.D., Little Rock
Jerry Chapman, M.D., Cabot
George H. Collier, Jr., M.D., Paragould
Neil E. Crow, Sr., M.D., Fort Smith
Maurice Elovitz, M.D., Horn Lake, Mississippi
Guy R. Farris, M.D., Little Rock
John F. Guenthner, M.D., Mountain Home
Robert W. Hunter, M.D., Magnolia
W. Payton Kolb, M.D., Little Rock
Harold J. Morris, M.D., Memphis, Tennessee
Joe C. Parker, M.D., Springdale
William J. Roberts, M.D., Charleston
Vance M. Strange, M.D., Stamps
Walton R. Warford, M.D., Little Rock
Auxiliary Members and Spouses:
Mrs. Lloyd Bess (Jane), Batesville
Mrs. Edgar Easley (Norma), Little Rock
Mrs. John T. Herron (Katherine), Little Rock
Mrs. Cecil Parkerson (Carolyn), Hot Springs
Mrs. D. Harvey Shipp (Katherine), Little Rock
554
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
.L.
Cardiology Commentary and Update
J. David Talley, M.D.*
Low-Molecular Weight Heparins
Low-molecular weight heparins (LMWH) are new
anticoagulants. This review will cover the cardiovas-
cular aspects of these new agents.
Mechanism of Action. Heparin was initially described
in 1916 and since then has been of substantial clinical
benefit in a variety of hypercoagulable and thrombo-
genic conditions.’ The association of anticoagulation
and antithrombotic activity is due to the mechanism
of action of heparin (Figure 1, left panel). Heparin in-
duces a conformational change in the plasma protein,
antithrombin III. Activated antithrombin III can inac-
tivate Factor Xa by itself, thereby inhibiting anticoagu-
lation. However, thrombin (factor Ila) inhibition re-
quires both heparin and activated antithrombin III. This
dual action of heparin, to inhibit both factor Xa and
thrombin, is the reason why heparin is both an anti-
coagulant and an antithrombin.
LMWHs were developed to dissociate the proper-
ties of anticoagulation and antithrombin activity of
heparin. These molecules are created by shortening
the length of the heparin chain. Varying the length of
the heparin side chains account for the variation in
molecular weight, relative activities against Xa and Ila,
plasma clearance, and dosage regimens of the various
LMWHs.
Like heparin, LMWH activates antithrombin III
(Figure 1, right panel). Activated antithrombin III in-
hibits Factor Xa in a fashion similar to heparin; but
thrombin is not inhibited because it requires both acti-
vated antithrombin III and the longer side chains of
heparin. Thus, LMWHs are relatively selective inhibi-
tors of factor Xa, but have little effect on thrombin (by
a factor of 3-4:1). LMWHs also have several other im-
portant differences from standard unfractionated he-
parin. Importantly, LMWHs are almost completely
absorbed with subcutaneous administration, need to
be administrated once to twice daily, and do not re-
quire dose adjustment based on laboratory monitor-
ing. They also do not cause hemorrhage, thrombocy-
topenia, or osteoporosis.
* Dr. Talley is with the Division of Cardiology, Department of
Internal Medicine, at UAMS.
Clinical indications. The approved indications for
LMWHs vary by country. Enoxaparin (Lovenox®,
Rhone-Poulenc Rorer Pharmaceuticals, Inc.,
Collegeville, PA, USA) the only FDA approved LMWH,
is used as prophylaxis of venous thromboembolic dis-
ease associated with moderate to high-risk orthopedic
surgeries. In other countries, enoxaparin is used to
prevent venous thromboembolism in patients under-
going general or cancer surgery, as treatment of deep
venous thrombosis, and to prevent thrombus forma-
tion during extracorporeal circulation for hemodialy-
sis.
Effect on restenosis. Neither enoxaparin and reviparin
(Knoll Ag, Ludwigshafen, Germany) reduced the rate
of restenosis in ERA (Enoxaparin Restenosis) trial or
the REDUCE (Reduction of Restenosis After PTCA,
Early Administration of Reviparin in a Double-Blind,
Unfractionated Heparin and Placebo-Controlled Evalu-
ation) study respectively.’'^ While both heparin and
LMWHs inhibit smooth muscle cell proliferation in
vitro, animal models of restenosis are notoriously mis-
leading in reproducing the human condition. Addi-
tionally, the dose of the agent may have been too low
in the clinical trials.
Unstable angina or non-Q-wave Ml. LMWHs stabi-
lize the clinical course of patients who present with an
acute ischemic coronary event (table 1). A small,
open-label study showed that nadroparin decreased
the occurrence of MI compared with aspirin alone or
the combination of aspirin and heparin.^ Enoxaparin
significantly reduced the combined endpoint of death,
MI, or recurrent angina pectoris compared with hep-
arin in the ESSENCE (Efficacy and Safety of Subcuta-
neous Enoxaparin in Non-Q wave Coronary Events)
trial.” There was a 63% reduction in relative risk of
death or MI (1.8% vs. 4.7%, p = 0.001) when dalteparin
was added to aspirin in the FRISC (Fragmin During
Instability in Coronary Artery Disease), (Fragmin®,
Pharmacia, Sweden) study. ^Conflicting data were re-
ported in the recent trial of inogatran where the com-
bined endpoint of death or MI occurred in 0.7% of
patients treated with heparin compared to 3.2% of patients
Volume 93, Number 11 - April 1997 555
Table 1: Trials Using Low-Molecular Weight Heparin in Unstable Angina or Non-O-wave Myocardial Infarction
dalteparin
(FRISC)
enoxaparin
(ESSENCE)’’
inogatran
(Grip, et al.)
nadroparin
(Gurfinkel, et al.)
No. of Patients
LMWH (death, MI) %
Control (death, MI) %
Relative risk reduction
P-value
1506
4.7%
1.8% (ASA)
-63%
0.001
3171
16.6%
19.8%
ASA + heparin)
-18%
0.018
1209
3.2%
0.7% (heparin)
NR
<0.05
219
0%
9.5% (ASA) t
6% ASA + heparin) tt
NR
0.01 t
0.1 tt
Abbreviations: ASA = acetylsalicylic acid; ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave
Coronary Events; FRISC= Fragmin During Instability in Coronary Artery Disease; LMWH = low molecular weight heparin; MI
= myocardial infarction; NR = not reported; NS = not significant (p>0.05)
Notes: *Endpoint data for the ESSENCE trial includes death, MI, or recurrent angina, the endpoint of the other trials is the
occurrence of death or MI; t nadroparin compared to ASA; tt nadroparin compared to ASA + heparin
treated with the investigational medication.’® A large
scale clinical trial (11 countries, 215 hospitals, and 3500
patients) is underway to test the efficacy and safety of
an uninterrupted enoxaparin administration compared
with heparin for the long-term out-patient manage-
ment of unstable ischemic coronary syndromes.”
Acute Myocardial Infarction. There is only limited
experience with the use of LMWHs in the setting of
acute MI. A non-randomized study demonstrated the
dalteparin and aspirin were effective in decreasing the
occurrence of ventricular thrombus after acute MI.”
References
1. McLean J. The thromboplastic action of cephalin. Am J
Physiol 1916;41 :250-256.
2. Bergqvist D, Benoni G, Bjorgell O, et al. Low-
molecular-weight heparin (enoxaparin) as prophylaxis against
venous thromboembolism after total hip replacement. N Engl
J Med 1996;335:696-700.
3. Geerts WH, Jay RM, Code KI, et al. A comparison of
low-dose heparin with low-molecular-weight heparin as pro-
phylaxis against venous thromboembolism after major
trauma. N Engl N Med 1996;335:701-707.
4. Product Insert, Lovenox® (enoxaparin sodium) Injection,
Rhone-Poulenc Rorer Pharmaceuticals, Inc., CoUegevUle, PA, USA
5. Faxon DP, Spiro TE, Minor S, et al; and the ERA investi-
gators. Low molecular weight heparin in prevention of
restenosis after angioplasty: Results of Enoxaparin Restenosis
(ERA) trial. Circulation 1994;90:908-914.
6. Karsch KR, Preisack MB, Baildon R, et al, on behalf of the
REDUCE trial group. Low molecular weight heparin
(reviparin) in percutaneous transluminal coronary
angioplasty: Results of a randomized, double-blind,
unfractionated heparin and placebo-controlled, multicenter
trial (REDUCE trial). J Am Coll Cardiol 1996;28:1437-1443.
7. Gurfinkel EP, Manos EJ, Mejai'I RI, et al. Low molecular
weight heparin versus regular heparin or aspirin in the treat-
ment of unstable angina and silent ischemia. J Am Coll
Cardiol 1995;26:313-318.
8. Cohen M, Demers C, Gurfinkel E, et al, ESSENCE group.
Primary end point analysis from the he ESSENCE trial:
enoxaparin vs unfractionated heparin in unstable angina and
non-Q wave infarction (abstract). Circulation 1996;94:1-554.
9. Fragmin during Instability in Coronary Artery Disease
(FRISC) study group. Low-molecular-weight heparin dur-
ing instability in coronary artery disease. Lancet
1996;347:561-568.
10. Grip L, Wallentin L, Dellborg M, et al. A low molecular
weight, specific thrombin inhibitor, inogatran, versus hep-
arin, in unstable coronary artery disease (abstract). Circula-
tion 1996;94:1-430.
11. Antman EM, McCabe CH, Marble SJ, et al. Dose ranging
trial of enoxaparin for unstable angina: results of TIMI 11 A
(abstract). Circulation 1996;94:1554.
12. Nesvold A, Kontny F, Abildgaard U, Dale J. Safety of
high doses of low molecular weight heparin in acute myo-
cardial infarction, a dose-finding study. Thromb Res
1991;64:579-587.
Figure 1: Left panel - The binding of heparin to anti-
thrombin III changes the structure of antithrombin III allow-
ing it to rapidly bind and inactivate factor Xa. To inactivate
thrombin, both heparin and activated antithrombin are required.
Right panel - Low-molecular weight heparin also changes
the structure of antithrombin III. Activated antithrombin III
can, by itself, inactivate factor Xa. The shorter glycosami-
noglycan side chains of low-molecular weight heparin can-
not bind to thrombin and it remains active.
From: Schafer Al. Low-molecular-weight heparin for venous
thromboembolism. Hosp Pract, January 15, 1997, pg. 100.
556
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The Medical Staff of Arkansas Children’s Hospital
and the University of Arkansas for Medical Sciences
Department of Pediatrics is pieased to announce an
expansion of the regional specialty clinic
program in Northwest Arkansas.
These clinics are located in Suite 704, Jones Clinio,
601 West Maple Avenue, Springdale, Arkansas.
ARKANSAS
CHTLDRFNS
H O S PI T A L
CH/LDReM'5 (/VfeS
Please call 501-700-3200 for more information.
Genetice
Endocrine
Arrhythmia
Hematology
Pulmonary
StAtc HeAkli WAtcl
1
Information provided by the Arkansas Department of Health. Division of Epidemiology
Meningococcal Disease in Arkansas
Meningococcal infections appear both as meningi-
tis and meningococcemia, and are a continuing seri-
ous health problem in Arkansas. In 1996, 34 cases and
six deaths were reported in the state. This compares
with the 1992-1996 annual average of 35 cases and 4
fatalities. (See Table 1.) The 5-year fatality rate for Ar-
kansas' cases was 13% for all meningococcal infections
reported, compared to CDC's reported case fatality rate
of 13% for meningitis and 11.5% for meningococcemia.
Serogroup B organisms predominate, causing 46%
(US) and 42% (Arkansas) of cases. Serogroup C iso-
lates are next in frequency, causing 45% (US) and 35%
(Arkansas). Other serogroups — A, Y, and W-135 —
are less often isolated.
Reports from the CDC indicate that the meningo-
coccus has replaced Haemophilus influenzae type B (Hib)
as the leading cause of meningitis in children, due to
effectiveness and increasing use of recently introduced
vaccines for Hib. The national picture is mirrored by
Arkansas' figures, which show a corresponding de-
crease in Hib meningitis since 1990. (Figures 1 and 2.)
A disproportionate number of cases (32%, 57 of 178)
of Arkansas' cases occurred in children under two years
of age during 1992-1996. This age group also recorded
35% of deaths caused by meningococcal disease (8 of
23) in that period. Overall, the age of cases ranged
from one month to 91 years. Meningococcal disease
occurs most frequently in late winter and spring.
Recent publication of guidelines for the control and
prevention of meningococcal disease by the Advisory
Committee on Immunization Practices (ACIP will as-
sist physicians and public health personnel in coping
with the expected spring increase in the incidence of
this disease. These guidelines were published by the
CDC in the MMWR February 14, 1997 / Vol 46 / No.
RR-5, entitled Control and Prevention of Meningococ-
cal Disease and Control and Prevention of Serogroup
C Meningococcal Disease: Evaluation and Management
of Suspected Outbreaks. These guidelines have been
excerpted for this article.
Control of meningococcal disease is accomplished
primarily by antimicrobial prophylaxis of close con-
tacts of case patients. Close contacts include a) house-
hold members, b) day care center contacts, and c) any-
one directly exposed to the patient's oral secretions.
This would include kissing, mouth-to mouth resusci-
tation, endotracheal intubation, or endotracheal tube
management. Household contacts have an attack rate
estimated to be four cases per 1,000 cases exposed,
which is 500-800 times greater than for the total popu-
558
lation. The rate of secondary disease is highest in the
first few days after onset of disease in the primary
patient. Prophylaxis should be administered as soon
as possible after the exposure is identified but, if pro-
phylaxis is delayed for 14 days or more, it is probably
of limited or no value.
Currently, three antimicrobials are recommended
for prophylaxis: rifampin, ciprofloxacin, and
ceftriaxone. Rifampin should not be used in pregnant
women, because the drug is teratogenic in laboratory
animals. Rifampin changes the color of urine to
reddish-orange and is excreted in tears and other body
fluids; it may cause permanent discoloration of soft
contact lenses. Because the reliability of oral contra-
ceptives may be affected by rifampin therapy, consid-
eration should be given to using alternate contracep-
tive measures while rifampin is being administered.
Ciprofloxacin is not generally recommended for
persons <18 years of age or for pregnant and lactating
women because the drug causes cartilage damage in
immature laboratory animals. However, a recent in-
ternational consensus report has concluded that
ciprofloxacin can be used for chemoprophylaxis when
no acceptable alternative therapy is available.
Systemic antimicrobial therapy of meningococcal
disease with agents other than ceftriaxone or other
third-generation cephalosporins may not reliably eradi-
cate nasopharyngeal carriage of Neisseria meningitidis.
If other agents have been used for treatment, the in-
dex patient should receive chemoprophylactic antibi-
otics for eradication of nasopharyngeal carriage before
being discharged from the hospital.
N. ??ieningitidis is the leading cause of bacterial
meningitis in older children and young adults in the
United States. The quadrivalent A, C, Y, and W-135
meningococcal vaccine available in the United states
is recommended for control of serogroup C meningo-
coccal disease outbreaks and for use among certain
high-risk groups, including a) persons who have ter-
minal complement deficiencies, b) persons who have
anatomic or functional asplenia, and c) laboratory per-
sonnel who routinely are exposed to N. meningitidis in
solutions that may be aerosolized. Vaccination may
also benefit travelers to countries in which disease is
hyperendemic or epidemic. Conjugate serogroup A
and C meningococcal vaccines are being developed by
using methods similar to those used for H. influenzae
type b conjugate vaccines, and the efficacies of several
experimental serogroup B meningococcal vaccines have
been documented in older children and young adults.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Culture confirmation and serogrouping is avail-
able at the Arkansas State Health Department Micro-
biology Laboratory. Whenever possible, isolates from
cerebrospinal fluid or blood cultures of patients with
suspected meningococcal disease should be referred,
both for the purpose of surveillance as well as possible
outbreak identification.
Table 1
Meningococcal case characteristics, by year
Arkansas, 1992-1996
1992
1993 1994
1995
1996
Total
Mean or %
Cases
23
27
55
39
34
178
35 (M)
Group
A
0
0
1
0
0
1
1%
B
4
0
13
13
13
43
42%
C
0
4
14
II
7
36
35%
Y
3
1
5
7
4
19
19%
Non-typable
0
0
0
1
1
2
2%
Under 2 yr
9
7
11
14
16
57
39%
Sex
M
18
14
19
15
16
82
47%
F
4
13
35
25
18
94
53%
Race
B
1
3
6
3
6
21
11%
W
22
24
48
32
28
174
89%
Deaths
6
4
4
3
6
23
13%
Meningitis, Meningococcal vs H. influenzae
us, 1990-1996
Year
3.500
3.000
2.500
2.000
1.500
1,000
5W
Cases
1990
1991
1992
1993
1994
1995
1996
MGC
2,451
2,130
2,134
2,637
2,886
3,243
3,176
H.inf ■ —
2,764
1,412
1,419
1,174
1,180
1,065
Figure 1
US 1996 totals are provisional
Meningitis, Meningococcal vs. H. influenzae
Arkansas, 1990-1996
Year
60
50
40
30
20
10
0
Cases
1990
1991
1992
1993
1994
1995
1996
MGC
25
25
23
27
49
39
34
H. Inf - —
31
16
5
8
4
6
1
Figure 2
Reported Cases of Selected Diseases in Arkansas Profile for January 1997
Selected
Reportable
Diseases
Total
Reported
Cases
Jan. 1997
Total
Reported
Cases
Jan. 1996
Total
Reported
Cases
1996
Total
Reported
Cases
1995
The three-month delay in the disease
Campylobacteriosis
15
13
241
153
profile for a given month is designed to
minimize any changes that may occur due
Giardiasis
14
12
183
131
to the effects of late reporting. The num-
Shigellosis
19
6
176
176
bers in the table reflect the actual disease
Salmonellosis
13
21
454
332
onset date, if known, rather than the date
Hepatitis A
27
67
507
663
the disease was reported.
Hepatitis B
3
11
91
83
HIB
0
0
0
6
Meningococcal Infections
2
6
34
39
Viral Meningitis
2
4
38
31
Lyme Disease
0
0
27
11
Rocky Mountain Spotted Fever
0
0
23
31
Tularemia
0
0
20
22
Measles
0
0
0
2
Mumps
0
0
1
5
Gonorrhea
351
448
5050
5437
Syphilis
23
65
706
1017
For a listing of reportable diseases in
Legionellosis
0
0
1
5
Arkansas, call the Arkansas Department
of Health, Division of Epidemiology, at
Pertussis
3
1
16
59
(501) 661-2893.
Tuberculosis
0
3
225
271
Arkansas HIV/AIDS Report
1983-1997
Distribution Of Cases
1983 through February 12, 1997
HIV Cases
(including AIDS)
Reported
□ 1 to3
□ 4 to 49
H 50 to 99
■ 100 to 1220
Arkansas Department of Health HIV/AIDS Surveillance Program
Demographics
83-89
1990
1991
1992
1993
1994
1995
1996
1997
Total
ra
s
c
Male
510
367
376
374
339
346
323
266
57
2,958
82
C
X
Female
64
67
87
76
89
89
89
78
20
659
18
Under 5
4
8
13
6
3
7
2
1
6
50
1
5-12
2
5
1
2
1
0
1
0
0
12
0
13-19
15
14
18
25
11
21
11
21
4
140
4
20-24
94
61
43
48
59
58
44
29
7
443
12
25-29
144
105
100
99
106
80
73
60
8
775
21
A
30-34
128
105
114
106
89
93
97
84
14
830
23
G
p
35-39
91
70
86
63
75
69
80
70
15
619
17
40-44
43
38
47
39
45
48
46
35
9
350
10
45-49
29
12
19
25
16
27
22
18
9
177
5
50-54
8
7
14
14
10
10
17
14
1
95
3
55-59
7
6
3
12
6
6
6
6
3
55
2
60-64
2
1
2
6
5
9
7
1
1
34
1
65 and older
7
2
3
5
2
7
6
5
0
37
1
R
White
385
290
280
280
264
244
253
187
35
2,218
61
A
Black
185
141
180
164
159
180
150
145
37
1,341
37
C
Hispanic
2
0
3
4
1
7
3
6
0
26
1
E
Other/Unknown
2
3
0
2
4
4
6
6
5
32
1
Male/Male Sex
327
229
239
246
231
211
164
127
15
1,789
49
Injection Drug
User (IDU)
77
65
89
71
62
71
54
27
7
523
14
R
Male/Male Sex
IX
1
+ IDU
77
37
32
37
28
23
28
22
1
285
8
s
Heterosexual
K
(Known Risk)
53
56
66
65
96
97
63
57
6
559
15
Transfusion
16
6
8
10
1
2
3
1
0
47
1
Perinatal
4
8
13
8
4
7
3
1
5
53
1
Hemophiliac
6
18
5
6
2
3
5
0
0
45
1
Undetermined
14
15
11
7
4
21
92
109
43
316
9
TOTAL
574
434
463
450
428
435
412
344
77
3,617
100
NOTE; County of residence may change from date of HIV test to date of AIDS diagnosis.
HIV Cases By County
County
1985-
2/12/97
Mar. 96-
Feb. 97
Arkansas
17
4
Ashley
19
*
Baxter
27
•
Benton
87
5
Boone
28
*
Bradley
15
*
Calhoun
7
0
Carroll
38
•
Chicot
17
0
Clark
15
7
Clay
*
*
Cleburne
13
*
Cleveland
•
0
Columbia
20
•
Conway
20
*
Craighead
62
6
Crawford
33
*
Crittenden
154
20
Cross
20
•
Dallas
8
*
Desha
17
4
Drew
12
•
Faulkner
62
*
Franklin
5
0
Fulton
•
*
Garland
133
12
Grant
*
0
Greene
22
4
Hempstead
20
*
Hot Spring
22
0
Howard
9
*
Independence
28
0
Izard
6
0
Jackson
7
*
Jefferson
160
23
Johnson
11
0
Lafayette
6
0
Lawrence
12
*
Lee
12
*
Lincoln
4
0
Little River
11
*
Logan
5
•
Lonoke
24
•
Madison
•
0
Marion
4
0
Miller
86
5
Mississippi
42
6
Monroe
13
•
Montgomery
6
0
Nevada
•
•
Newton
5
*
Ouachita
31
*
Perry
5
0
Phillips
34
4
Pike
*
0
Poinsett
15
•
Polk
12
•
Pope
54
*
Prairie
6
0
Pulaski
1220
94
Randolph
5
*
St. Francis
72
11
Saline
24
•
Scott
•
0
Searcy
4
*
Sebastian
202
5
Sevier
10
•
Sharp
10
*
Stone
•
*
Union
115
15
Van Buren
5
0
Washington
276
33
White
34
6
Woodruff
4
0
Yell
11
•
Prisons
96
12
• Case numbers of 1-3 are not reported.
560
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Arkansas HIV/AIDS Report
1983-1997
Distribution Of Cases
1983 through February 12, 1997
AIDS Cases
Reported
□ 1 to 3
□ 4 to 49
□ 50 to 99
■ 100 to 716
Arkansas Department of Health HIV/AIDS Surveillance Program
Demographics
83-89
1990
1991
1992
1993
1994
1995
1996
1997
Total
%
s
Male
231
162
171
243
325
253
238
212
29
1,864
86
C
X
Female
21
19
25
34
63
42
35
54
9
302
14
Under 5
2
6
6
3
2
1
2
0
6
28
1
5-12
1
1
1
0
1
0
2
0
0
6
0
13-19
0
4
3
2
4
3
1
3
1
21
1
20-24
23
10
14
14
31
22
11
14
2
141
7
25-29
58
41
42
65
78
45
46
46
4
425
20
A
30-34
62
44
42
70
95
80
75
75
7
550
25
G
F
35-39
53
32
37
55
77
52
49
54
9
418
19
40-44
21
18
33
27
48
40
35
37
3
262
12
45-49
12
14
6
22
26
22
17
21
3
143
7
50-54
4
5
5
7
10
12
15
4
1
63
3
55-59
8
1
4
8
8
5
6
7
1
48
2
60-64
3
1
1
2
5
10
5
1
0
28
1
65 and older
5
4
2
2
3
3
9
4
1
33
2
R
White
192
133
132
200
264
189
174
144
21
1,449
67
A
Black
57
46
63
73
120
103
96
116
16
690
32
C
E
Hispanic
1
0
1
3
3
2
3
4
0
17
1
Other/Unknown
2
2
0
1
0
1
0
2
1
9
0
Male/Male Sex
Injection Drug
142
112
114
175
229
162
136
117
11
1,198
55
R
User (IDU)
Male/Male Sex
27
17
29
41
67
47
47
26
2
303
14
1
s
+ IDU
Heterosexual
49
19
21
27
29
25
24
22
1
217
10
K
(Known Risk)
15
10
11
20
52
41
34
52
4
239
11
Transfusion
13
7
8
6
1
4
3
2
0
44
2
Perinatal
2
6
6
3
3
1
3
0
5
29
1
Hemophiliac
2
5
5
4
5
6
7
1
0
35
2
Undetermined
2
5
2
1
2
9
19
46
15
101
5
TOTAL
252
181
196
277
388
295
273
266
38
2,166
100
NOTE: County of residence may change from date of HIV test to date of AIDS diagnosis.
Volume 93, Number 11 - April 1997
AIDS Cases By County
County
1983-
2/12/97
Mar. 96-
Feb. 97
Case Rale
Per 100,000
Arkansas
9
0
0.0
Ashley
15
•
4.1
Baxter
22
0
0.0
Benton
70
7
7.2
Boone
22
*
10.6
Bradley
11
*
17.0
Calhoun
6
*
17.2
Carroll
23
0
0.0
Chicot
10
•
12.7
Clark
10
*
14.0
Clay
*
*
5.5
Cleburne
7
0
0.0
Cleveland
4
0
0.0
Columbia
15
•
7.8
Conway
14
0
0.0
Craighead
44
4
5.8
Crawford
26
*
2.4
Crittenden
77
14
28.0
Cross
10
•
15.6
Dallas
5
*
10.4
Desha
8
*
6.0
Drew
7
*
5.8
Faulkner
47
6
10.0
Franklin
4
0
0.0
Fulton
*
0
0.0
Garland
81
14
19.1
Grant
•
*
7.2
Greene
12
•
9.4
Hempstead
11
*
9.3
Hot Spring
16
•
7.7
Howard
6
0
0.0
Independence
15
0
0.0
Izard
5
*
8.8
Jackson
4
0
0.0
Jefferson
87
16
18.7
Johnson
7
0
0.0
Lafayette
*
0
0.0
Lawrence
11
•
5.7
Lee
7
0
0.0
Lincoln
4
0
0.0
Little River
5
0
0.0
Logan
6
*
4.9
Lonoke
22
•
2.5
Madison
4
0
0.0
Marion
4
0
0.0
Miller
46
6
15.6
Mississippi
16
4
7.0
Monroe
6
*
8.8
Montgomery
5
0
0.0
Nevada
*
*
9.9
Newton
•
0
0.0
Ouachita
21
•
3.3
Perry
4
0
0.0
Phillips
19
4
13.9
Pike
*
0
0.0
Poinsett
8
•
4.1
Polk
9
*
5.8
Pope
26
*
2.2
Prairie
5
0
0.0
Pulaski
716
81
23.2
Randolph
*
*
6.0
St. Francis
33
8
28.1
Saline
17
*
3.1
Scott
•
0
0.0
Searcy
4
•
12.8
Sebastian
122
6
6.0
Sevier
8
*
7.3
Sharp
8
*
21.3
Stone
•
0
0.0
Union
67
10
21.4
Van Buren
4
0
0.0
Washington
167
22
19.4
White
18
*
3.7
Woodruff
4
0
0.0
Yell
8
•
11.3
Prisons
31
7
N/A
* Case numbers of 1-3 are not reported.
561
Pledging commitment is one of the most important
things that human beings can do for one another. It
means I'll do only my best for you. I'll fight for your
rights. I'll be there for you.
At Snell Laboratory we make that type of commitment to
each of our patients. We dedicate ourselves to making
them as comfortable and as mobile as possible. We give
them back as much of their former life as we can.
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THE LATEST IN TECHNOLOGY. THE BEST IN CARE.
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Little Rock (501) 664-2624 • Statewide Foil-free 1-800-342-5541
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attending a special occasion, our commitment
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Snell Prosthetic and Orthotic Laboratory has
been in business since 1911. We've said "I do" to
our patients since day one.
New Members
ASHDOWN
Kleinschmidt, Kevin C., Family Practice. Medical
Education, Southwestern Medical School, Dallas,
Texas, 1984. Internship/Residency, Wichita Falls Fam-
ily Practice Residency, 1985/1987. Board certified.
CAMDEN
Feld, Sheldon Michael, Family Practice. Medical
Education, Queen's University, Kingston, Ontario,
Canada, 1970. Internship, Scarborough General Hos-
pital, 1971.
CHEROKEE VILLAGE
Kleinschmidt, Kevin C., Family Practice. Medical
Education, Southwestern Medical School, Dallas,
Texas, 1984. Internship/Residency, Wichita Falls Fam-
ily Practice Residency, 1985/1987. Board certified.
Gupta, Atul, Pediatrics. Medical Education, All
India Institute of Medical Science, India, 1989. Resi-
dencies, All India Institute of Medical Sciences, 1994,
and Rush Presbyterian St. Lukes Medical Center, Chi-
cago, Illinois, 1996. Board certified.
FORREST CITY
Salvador, Ester Arejola, Psychiatry. Medical Edu-
cation, University of Santo Tomas School of Medicine
and Surgery, Espana, Manila, Philippines, 1965. In-
ternship, USTH, 1965. Residency, Texas Tech UHSC,
Lubbock, Texas, 1996.
FORT SMITH
McCoy, Daniel Wyatt, Cardiothoracic Surgery.
Medical Education, Medical College of South Carolina,
Charleston. Internship and Residency, University of
Mississippi, Jackson, 1990/1994. Residency, University
of Tennessee, Memphis, 1996. Board certified.
Queeney, Joseph, Neurological Surgery. Medical
Education, Oklahoma State University College of Os-
teopathic Medicine and Surgery, Tulsa, 1989. Intern-
ship, Enid Regional Hospital, 1990. Residency, Doc-
tors Hospital, Columbus, Ohio, 1996. Board certified.
Tait, Amy Simpson, Pediatrics. Medical Educa-
tion, University of Kansas, Kansas City, 1986. Intern-
ship/Residency, Indiana University, 1989. Board certified.
HOT SPRINGS
Grose, Andrew J., Internal Medicine. Medical
Education, UAMS, 1992. Internship/Residency, UAMS,
1993/1995. Board certified.
JACKSONVILLE
Dhaliwal, Harminder Singh, Pediatrics. Medical
Education, Government Medical College, Patiala, In-
dia, 1976. Internship, Government Medical College,
Patiala, India, 1977. Residency, Children's Hospital of
Austin, Texas, 1996.
Price, John Gordon, Internal Medicine. Medical
Education, UAMS, 1993. Internship/Residency, UAMS,
1994/1996. Board eligible.
JONESBORO
Kelly, Scott Matthew, Emergency Medicine. Medi-
cal Education, University of Texas Health Science Cen-
ter, San Antonio, 1992. Internship, University of Ten-
nessee, Memphis, 1993. Residency, Baptist Hospital,
Memphis.
McClurkan, Michael Bruce, Obstetrics/Gynecol-
ogy. Medical Education, UAMS, 1992. Internship/Resi-
dency, UAMS, 1993/1996.
LITTLE ROCK
Grissom, James R., Medical Oncology and He-
matology. Medical Education, UAMS, 1975. Internship,
UAMS, 1976. Residency, Tulane University Medicine
Program, New Orleans, 1979. Board certified.
Heard, Adele, Pediatrics. Medical Education,
UAMS, 1993. Internship/Residency, Arkansas
Children's Hospital, 1994/1996. Board pending.
Ironside, John Brett, Neurology. Medical Educa-
tion, UAMS, 1992. Internship/Residency, 1993/1996.
Board eligible.
Kulik, Steven A., Jr., Orthopedic Surgery. Medi-
cal Education, Tulane University, New Orleans, 1984.
Internship, U. S. Army, Brooke Army Medical, San
Antonio, Texas, 1985. Residency, U.S. Army, William
Beaumont Army, El Paso, Texas, 1990. Fellowship,
University of Texas, Houston, 1993. Board certified.
Lovett, Angela Robinette, Anesthesiology. Medi-
cal Education, UAMS, 1991. Internship/Residency,
UAMS, 1992/1995. Board eligible.
MAYFLOWER
Beasley, Thomas O., Family Practice. Medical
Education, UAMS, 1970. Internship, St. Vincent Hos-
pital, 1971. Board certified.
NASHVILLE
Martinazzo-Dunn, Anna, Psychiatry/Child & Ado-
lescent Psychiatry. Medical Education, University of
Turin, Italy, 1977. Internship/Residency, Rush Presby-
terian St. Luke's Medical Center, Chicago, Illinois, 1983.
Fellowship, Institute for Juvenile Research, Chicago,
Illinois, 1985. Board certified.
PARAGOULD
Brown, Howard S., Gastroenterology. Medical
Education, University of Illinois, Chicago, 1970. In-
ternship/Residency, L.A. County - U.S.C. Medical
Center, 1971/1973. Fellowship, Kaiser Foundation Hos-
pital, 1975.
Volume 93, Number 11 - April 1997
563
PINE BLUFF
Kremp, Richard Edward, Radiology. Medical Edu-
cation, Indiana University School of Medicine, India-
napolis, 1963. Internship, St. Vincent Hospital, 1964.
Residency, Vanderbilt University Medical Center, 1972.
Board certified.
SEARCY
Sanchez-Montserrat, Rafael, Internal Medicine/
Pulmonology. Medical Education, School of Medicine,
University of Barcelona, Spain, 1972. Internships, San
Juan City Hospital, P.R. Medical Center, 1975. Resi-
dency, San Juan VA Hospital, 1977.
SPRINGDALE
Sandler, Richard, Endocrinology. Medical Educa-
tion, New York University School of Medicine, 1963.
Internship/Residency, Bellevue Hospital, 1964/1965.
Residencies, Bellevue Hospital, 1965; Harvard, North-
western University, 1968; and Beth Israel Hospital, Bos-
ton, 1969. Board certified.
TILLY
Hollabaugh, Denise Thormahlen, General Prac-
tice. Medical Education, Louisiana State University
Medical Center, Shreveport, 1986. Internship, E.A.
Conway Hospital, Monroe, Louisiana, 1987.
RESIDENTS
Adler, Jodi Lynn, Eamily Practice. Medical Edu-
cation, University of Osteopathic Medicine and Health
Sciences, Des Moines, Iowa, 1996. Internship/Resi-
dency, UAMS.
Albanna, Ahmed Q.S., Neurology. Medical Edu-
cation, Arabian Gulf University, Bahrain, 1992. Intern-
ship, UAMS, 1996. Residency, UAMS.
Chen, Jing Xuan, Anesthesiology. Medical Edu-
cation, The 4'*’ Military Medical University, Xian, PR
China, 1983. Residency, UAMS.
Corder, Fred A., Internal Medicine/Gastroenter-
ology. Medical Education, UAMS, 1994. Internship,
UAMS, 1995. Residency/Fellowship, UAMS.
Hajiamiri, Majid, Neurology. Medical Education,
Istanbul Medical School, Turkey, 1991. Internship,
UAMS, completed. Residency, UAMS.
Henry, Mary Jo, Radiology. Medical Education,
University of Tennessee, Memphis, 1994. Residency,
UAMS.
Karim, MD, Rezaul, Physical Medicine & Reha-
bilitation. Medical Education, Mymensingh Medical
College, Bangladesh, 1981. Internship, Mymensingh
Medical College Hospital, completed. Residency,
UAMS.
Kumar, Ashok, Internal Medicine and Hematol-
ogy/Oncology. Medical Education, Kilpauk Medical
College, Madras, India, 1986. Internship/Residency,
New Hanover Regional Medical Center, Wilmington,
NC. Fellowship, UAMS.
Leek, Grif Alan, Emergency Medicine. Medical
Education, Louisiana State University, New Orleans,
1995. Internship/Residency, UAMS.
564
Malik, Vipin, Internal Medicine. Medical Educa-
tion, Maulana Azad Medical College, New Delhi, In-
dia, 1993. Internship, Maulana Azad Medical College.
Residency, UAMS.
McLaughlin, Shannon Gay, Internal Medicine/
Geriatrics. Medical Education, UAMS, 1989. Intern-
ship/Residency, UAMS, 1990/1992. Fellowship, UAMS.
Minton, Bryan Howard, Family Medicine. Medi-
cal Education, UAMS, 1995. Internship, AHEC-NW,
Fayetteville, 1996. Residency, AHEC-NW, Fayetteville.
Newton, J. Camp, Anesthesiology. Medical Edu-
cation, UAMS, 1993. Internship, UAMS, 1994. Resi-
dency, UAMS.
Prada, Stefan Alexander, Orthopedic Surgery.
Medical Education, Albany Medical College, New York,
1991. Internship, Emory University School of Medi-
cine, Atlanta, Georgia, 1992. Residency, UAMS.
Sadikot, Ruxana T. Medical Education, Grant
Medical College, 1988. Internship, UAMS.
Stark, Karen Lynn, Ophthalmology. Medical Edu-
cation, Washington University, St. Louis, Missouri,
1996. Internship/Residency, UAMS.
Verbois, Glennal Moore, Physical Medicine &
Rehabilitation. Medical Education, Louisiana State Univer-
sity, New Orleans, 1993. Intemship/Residency, UAMS.
STUDENTS
Cheryl Lynn Ahart
Angela Yvonne Anthony
Kimberly Ann Booth
Columbus Brown
Ryan Paul Buffalo
Arlean Michelle Bullard
Mildred Murphy Clifton
Christopher D. Cochran
Delilah Latrece Easom
Kimberley Janet Farmer
Daniel Henry Felton, IV
Timothy Edward Freyaldenhoven
Kevin Gaines
William Cody Grammer
Janna L. Helmich
Chris Howell Horan
Donna-Marie Koroma
Billy James Layton
Rebecca Leigh Latch
Robert Scott Lowery
Laura Anne Massey
James R. Maxwell
Jamie Lynn McGrew
Gregory Allen McKenzie
Scott C. Moran
Christopher Osburn Morgan
John Ray Nolen
Sheryl Denise Pack
Erik C. Parker
Russell L. Roberts, Jr.
Lena Jane Rose
John Preston Scurlock
Michael Hamilton Sifford
Jeffrey D. Stamp
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Jennifer Ann Steeger
Robert Lloyd Stuckey
Tommy Gene Taylor
Jefferson Robert Thurlby
Sage V. Thurlby
Felicia A. Watkins-Brown
Veronica Lynn Williams
Radiological Case
of the Month
Steven R. Nokes, M.D., Editor
Authors
Ronald C. Walker, M.D.
John M. Hayes, M.D.
David W. Bevans, M.D.
Steven R. Nokes, M.D.
History:
A 47 year old white female presented with recurrent hyperparathyroidism. She had a neck exploration 10 months
previously, initially successful in controlling her hyperparathyroidism. Prior to re-exploration of her neck, a CT scan of
the neck and upper mediastinum was performed (Fig. 1), as well as a Tc-99m Sestamibi scan (Figures 2-4).
Figure 1
Figure 2
IMMEDIATE IMAGES
Figure 3
Figure 4
Figures:
Figure 1; CT scan of the upper mediastinum
Figures 2-4: Tc-99m Sestamibi scans
Volume 93, Number 11 - April 1997 565
I I ■■■Ml
Ectopic parathyroid adenoma of the upper mediastinum
Diagnosis: Ectopic parathyroid adenoma of the upper mediastinum
Findings:
The region of increased uptake oftheTc-99m sestamibi corresponds to the location of the low density mass seen
on the CT scan, anterior to the left innominate vein (arrow). This focal region of abnormal activity diminishes over
time, in this particular instance at about the same rate of loss of activity in the thyroid. Ectopic thyroid glands could
have this appearance, but ectopic thyroid glands do not occur in euthyroid patients with normally located thyroid
glands; therefore, this upper mediastinal focal activity is abnormal.
Discussion:
Preoperative localization of parathyroid adenomas is difficult. Most authorities do not feel that preoperative imag-
ing is needed in the vast majority of hyperparathyroid patients who present for their initial exploration. Since preopera-
tive imaging is poor at detecting and localizing parathyroid hyperplasia (as opposed to parathyroid adenomas), an
exploration of the neck is indicated regardless of the outcome of the preoperative imaging, in patients with no prior
surgical intervention. Ectopic parathyroid adenomas in the mediastinum are rare.
Once a patient has had a neck exploration, a second surgical intervention (as in this case) is a great deal more
difficult. Thus, preoperative localization attempts are generally indicated for patients with prior neck exploration.
Tc-99m sestamibi uptake by parathyroid adenomas is poorly understood and variable. The agent generally fol-
lows metabolism; hence, it is accumulated in areas of increased cellular metabolic rate (malignancies, cardiac muscle,
and adenomas, to name a few). Since sestamibi may clear from the parathyroid adenoma slower, at the same rate
as, or more rapidly than the thyroid gland, it is important to image the patient at several time frames to best detect an
adenoma. In this case, we found an ectopic parathyroid gland in the upper mediastinum. The patient had the region
surgically excised, with the pathologist reporting a cystic parathyroid adenoma. Her hyperparathyroid condition re-
solved.
Preoperative localization of parathyroid adenomas with Tc-99m sestamibi is a simple and useful technique in the
hyperparathyroid patient, particularly with an unsuccessful neck exploration or recurrent disease. The technique is
easier to perform and statistically superior to the Tc-99m/T1-201 dual isotope subtraction study. No imaging tech-
nique is, as yet, of significant benefit in patients with parathyroid hyperplasia.
References:
1. Malhotra, A, et. al.. Preoperative Parathyroid Localization with Sestamibi. Am J Surg. 1996:172:637-640.
2. Martin, D., Rosen, I.B., Ichise, M. Evaluation of Single Isotope Technetium 99m-Sestamibi in Localization Efficiency for
Hyperparathyroidism. Am J Surg. 1996;172:633-636.
Authors:
Editor: Steven R. Nokes, M.D., is associated with Radiology Consultants in Little Rock.
Contributor: Ronald Walker, M.D., is associated with Radiology Consultants in Little Rock.
Contributor: John M. Hayes, M.D., is associated with the Pulaski Surgery Clinic.
Contributor: David W. Bevans, M.D., is associated with the Pulaski Surgery Clinic.
566
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
In Memoriam
Harold Joseph Morris, M.D.
Dr. Harold Joseph Morris of Pine Bluff died Monday, February 17, 1997.
He was 82. He is survived by his wife, Molly Malone Morris; daughters, Sarah
Johnson of Cincinnati, Ohio, and Judith J. Morris of Bartlett, Tenn.; brother,
Sheppard Morris of Memphis; and two grandchildren. A daughter, Linda
Frances Morris, died in 1986.
Things To Come
May 1-3
Arkansas Medical Society Annual Session - Scal-
ing New Heights. Arlington Hotel, Hot Springs. For
more information, call 1-800-542-1058 or 501-224-8967.
May 8-10
Ambulatory Surgery '97: Sharing Our Experiences
FASA 23rd Annual Meeting. Marriott Copley Place
Hotel, Boston, MA. For more information, call (703)
836-8808.
May 21-24
National Rural Health Association 20th Annual
National Conference: Caring for the country.. .Partnerships
for Health. Westin Hotel, Seattle, Washington. For more
information, write to NRHA, One West Armour Bou-
levard, Suite 301, Kansas City, Missouri, 64111.
June 6-8
Alumni Weekend '97 - University of Arkansas
College of Medicine Alumni. Alumni Classes of 1932,
1937, 1942, 1947, 1952, 1957, 1962, 1967, 1972, 1977,
1982 and 1987 will be reuniting this year for a variety
of special activities beginning on Friday afternoon, June
6th and ending with a brunch on Sunday, June 8th.
All alumni and Caduceus Club members are welcome
to attend. Call the Arkansas Caduceus Club at (501)
686-6684 for registration forms and more information.
July 7-10
17th Annual Current Concepts in Primary Care
Cardiology. Hyatt Regency Lake Tahoe, Incline Vil-
lage, Nevada. Sponsored by UC Davis School of Medi-
cine and Medical Center, Division of Cardiovascular
Medicine and Office of Continuing Medical Education.
For more information, call (916) 734-5390.
September 5-7
4th Annual Current Topics in Cardiothoracic An-
esthesia. Washington University Medical Center, St.
Louis, Missouri. Sponsored by the Office of Continu-
ing Medical Education, Washington University School
of Medicine. For more information, call 1-800-325-9862.
September 18-20
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
October 26-30
1997 State-of-the-Art Conference: Occupational
and Environmental Medicine. Nashville, Tennessee.
Sponsored by the American College of Occupational
and Environmental Medicine. Eor more information,
call (847) 228-6850, ext. 152.
AMS Sponsors Workshops
in Little Rock
October 16, 1997
Managed Care Update:
Advanced Strategies for Practice Survival
This workshop will show you how to become more pro-
active in the managed care marketplace. Numerous case
examples will be used to illustrate the following topics:
getting into the better plans; tracking managed care plan
results; reorganize some of the staff jobs; learn about out-
come studies; and determine ways to reduce practice over-
head in a reduced-reimbursement environment.
December 4, 1997
Coding Analysis to Maximize
Reimbursement in 1997
A hands-on workshop with informative case studies. Ma-
jor emphasis is on the complex relationship between the
procedure, the diagnosis, place of service, provider sta-
tus and patient financial class for traditional and non-tra-
ditional (HMO/PPO) claims processing. Workshop requires
a background in the basics of CPT, ICD-9 and the HCFA- 1500.
For more information call 501-224-8967
Volume 93, Number 11 - April 1997 567
WesHem Wildlife
As Kasirnirrs iimvfij ttVst. pimieers L L C
roiind,afiimuU as exotic a& ilie land:
buffalo, prame dog:s, bears. beaverl/Ughorrr *'/
slirep, cougars, vulves und rattlesrfcll^s.
The eagle became a national symbol. < •; i ' ‘
tc '
^ \ he eagle became a national symbol. < •; i ' ‘ * • /
A'i^iaoCuioJ^'^ry^^ .
thank y^’^-
m made it
liave a
n I had no
^ I did not
suchaproi
,ededpro&
Id like to su
YourpnoS^
hie for
tmogra^^
re else to tn
lize there
t is a much ‘
,nnks again
fynen /,
c^ttentior,
^owYedi
" Medical
blessed
y^pyogram
rind helpful
me.
tor more
information
on how
you can help,
call AHCAF at
(501) 221-3033
r (800) 950-823
AricansasH^th^l^
Access Foundatiwi, Inc,
those physicians^ho volunteer
through the Arkansas Health
C.are Access Foundation^
As you can see fr om a sampling of
- letters we have^received, your
l^, involvement in our program Js k
THANK YOU FOR MAKING THE DIFFERENCE!
Keeping Up
May 30 - June 1
19th Annual Family Practice Intensive Review. Location: UAMS,
Education II Building, Little Rock. Program Presenters: Department
of Family and Community Medicine. Aecrediting organization spon-
soring program: UAMS College of Medicine. Hours of Category 1
credit offered: Up to 20 hours of CME credit. Fee: TBA. For more
information, call 501-661-7962.
October 3-5
Primary Care Update (Management of Top 20 Ambulatory Di-
agnoses). Location: Gaston's Lodge on the White River. Sponsor:
Washington Regional Medical Center. For more information, call
501-442-1823 or 1-800-422-0322.
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category 1 of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
FAYETTEVILLE-WASHINGTON REGIONAL MEDICAL CENTER
Cardiology Conference, 3rd Wednesday of every month, 7:30 - 8:30 a.m., WRMC, Baker Conference Center, no fee, breakfast provided
Chest Conference, 1st Wednesday of every month, 12:15 - 1:15 p.m., WRMC, Baker Conference Center, no fee, lunch provided
Primary Care Conferences, every Monday, 12:15 - 1:15 p.m., WRMC, Baker Conference Center, no fee, lunch provided
Tumor Conference, every Thursday, 7:30 - 8:30 a.m., WRMC, Baker Conference Center, no fee, breakfast provided
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Breast Conference, 3rd Thursday, 7:00 a.m., J.A. Gilbreath Conference Center, Room #20
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Disorders Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
The University of Arkansas College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor the
following continuing medical education activities for physicians. The Office of Continuing Medical Education designates that these activities
meet the criteria for credit hours in category 1 toward the AM A Physician's Recognition Award. Each physician should claim only those
hours of credit that he/she actually spent in the educational activity.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Volume 93, Number 11 - April 1997
569
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Pertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Petal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
570
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Obstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology /Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
FORT SMITH-AHEC
Grand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/ Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Greenleaf Hospital CME Conference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
nternal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 11 - April 1997 571
iiinMiiriPMffPiiiiiiiiiiiiiii^^ III mill iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiuiiwiwiiiiirf
Advertisers Index
Advertising Agencies in italics
AMS Benefits inside back
Arkansas Children's Hospital 557
Autoflex Leasing inside front
Freemyer Collection System 516
Med Plus Leasing 549
McNabb, Kelley & Barre
Medical Practice Consultants, Inc 515
Riverside Motors, Inc 510
Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory 562
Strategic Marketing
State Volunteer Mutual Insurance Company ... back cover
The Maryland Group
Southwest Capital Management 538
Marion Kahn Communications, Inc.
U.S. Air Force 509
BJK&E Specialized Advertising
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
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For a reprint price list, contact Tina G. Wade, Managing
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HEALTH SCrE^\ICES LIBRARY .
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FINALLY, a health insurance plan designed to meet the needs of Arkansas' physicians. The ARKANSAS
MEDICAL SOCIETY HEALTH BENEFIT PROGRAM... offering a variety of benefit options including a choice
between basic indemnity and managed care. For information call (501) 224-8967 or 1-800-542-1058.
Arkansas Medical Society
Health Benefit Program
Underwritten by
American Investors
Life Insurance Company
In cooperation with
Arkansas Managed
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Exclusively for members of the Arkansas Medical Society. Developed by AMS BENEFITS, INC. in conjunction with American
Investors Life and Arkansas Managed Care Organization.
AMS BENEFITS, INC
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MANAGING EDITOR
Tina G. Wade
EXECUTIVE VICE PRESIDENT
Kenneth LaMastus, CAE
ASSISTANT EXECUTIVE VICE
David Wroten
PRESIDENT
THE JOURNAL
OF THE ARKANSAS
MEDICAL SOCIETY
EDITORIAL BOARD
Jerry Byrum, M.D.
David Barclay, M.D.
Lee Abel, M.D.
Samuel Landrum, M.D.
Ben Saltzman, M.D.
Alex Finkbeiner, M.D.
Pediatrics
Obstetrics/ Gynecology
hitertml Medicine
Surgery
Family Practice
UAMS
Volume 93 Number 12
May 1997
CONTENTS
FEATURES
EDITOR EMERITUS
Alfred Kahn Jr., M.D.
ARKANSAS MEDICAL SOCIETY
1996-97 OFFICERS
John Crenshaw, M.D., Pine Bluff
President
Charles Logan, M.D., Little Rock
President-elect
Jim Crider, M.D., Harrison
Vice President
James Armstrong, M.D., Ashdown
Immediate Past President
Mike Moody, M.D., Salem
Secretary
Lloyd Langston, M.D., Pine Bluff
Treasurer
Anna Redman, M.D., Pine Bluff
Speaker, House of Delegates
Kevin Beavers, M.D., Russellville
Vice Speaker, House of Delegates
Gerald Stolz, M.D., Russellville
Chairman of the Council
576 Medicine in the News
Health Care Access Foundation Update
History of Medicine Associates Research Award
AIDS Deaths Decline
CLIA Fact Sheets by Fax Program Expanded by COLA and CDC
Disciplinary Action Bulletin - Arkansas State Board of Nursing
582 The Patient-Physician Relationship: Covenant or Contract?
Special Article
James T.C. Li, M.D., Ph.D.
585 Investment Advice - Who Do You Call?
Larry Waschka
587
589
A Good History Usually Gives a Diagnosis
Loss Prevention
]. Kelley Avery, M.D.
NEW SECTION!]
Emergency Medicine
New Quarterly Section
Delayed cardiac tamponade following a stab wound: a case report
Jerel Lee Raney, M.D.
Elicia Sinor Kennedy, M.D.
604 Cumulative Index, Volume 93, Numbers 1-12
Established 1890. Owned and edited by the Arkan-
sas Medical Society and published under the direction
of the Council.
Advertising Information: Contact Tina G. Wade, The
Journal of the Arkansas Medical Society, P.O. Box 55088,
Little Rock, AR 72215-5088; (501) 224-8967.
Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.
Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.
The Journal of the Arkansas Medical Society (ISSN
0004-1858) is published monthly by the Arkansas
Medical Society, #10 Corporate Hill Drive, Suite 300,
Little Rock, Arkansas 72205. Printed by The Ovid Bell
Press, Inc., Fulton, Missouri 65251. Periodicals postage
is paid at Little Rock, Arkansas, and at additional
mailing offices.
Articles and advertisements published in The Journal
are for the interest of its readers and do not represent
the official position or endorsement of The Journal or the
Arkansas Medical Society. The Journal reserves the right
to make the final decision on all content and
advertisements.
Copyright 1997 by the Arkansas Medical Society.
DEPARTMENTS
580 AMS Newsmakers
592 Cardiology Commentary & Update
594 State Health Watch
596 New Members
599 Resolutions
600 Things to Come
601 Keeping Up
Cover artwork titled "White Water” is by Jonesboro artist Marion Sue Thompson. Artwork made
available by the Arkansas Artists Registry, a part of the Arkansas Arts Council, an agency of the
Department of Arkansas Heritage.
Medicine in the News
Health Care Access Foundation
As of April 1, 1997, the Arkansas Health Care Ac-
cess Foundation has provided free medical service to
12,444 medically indigent persons, received 23,649 ap-
plications and enrolled 46,075 persons. This program
has 1,752 volunteer health care professionals includ-
ing medical doctors, dentists, hospitals, home health
agencies and pharmacists. These providers have ren-
dered free treatment in 69 of the 75 counties.
History of Medicine Associates Research
Award
A History of Medicine Associates Research Award,
in the amount of $1,000, is being offered to an appli-
cant who is interested in preparing a paper on an as-
pect of the health sciences in Arkansas. Half of the
award will be presented when the proposal is accepted
and the other half on completion of the paper. The
Award is for research in the history of the health sci-
ences in Arkansas on a topic which makes use of the
UAMS Library's Special Collections Division in addi-
tion to other research collections.
The award may be used at the discretion of the
recipient to cover expenses for travel, housing, mate-
rials, research or secretarial assistance or other costs
directly related to the project.
Upon completion of the paper, the author will re-
ceive a certificate in recognition of the award.
A copy of the paper becomes the property of the
UAMS Special Collections Division and will be depos-
ited there.
The Associates will assist the author in submitting
the paper for publication but publication cannot be
assured.
Application Information
The goal of the Award is to encourage research in
the history of the health sciences. Applicants are sought
not only from the discipline of the health sciences but
also from other disciplines, e.g., history, sociology and
health administration. The application must include a
summary of the paper's topic, a proposed budget, and
an anticipated completion date for the paper. The dead-
line for applications for the award is May of each year.
The announcement of the recipient of the award will
be made in June. A committee of the History of Medi-
cine Associates will determine the successful appli-
cant. Applications and/or guidelines for application may
be requested from: Edwina Walls, Treasurer, History
of Medicine Associates, UAMS Library, Slot 586, 4301
W. Markham, Little Rock, AR 72205-7186 or call 501-
686-6733.
AIDS Deaths Decline
An ongoing nationwide surveillance system has
allowed the Centers for Disease Control to track AIDS
incidence, morbidity and mortality since 1981. Now,
for the first time in fifteen years, the curves are begin-
ning to change.
In the first six months of 1996, the incidence of
AIDS and of AIDS-associated opportunistic infections
was comparable to figures from previous years. How-
ever, AIDS mortality, which increased steadily through
1994, increased only minimally in 1995 and declined
more than 10% during the first six months of 1996.
Deaths declined in all regions of the U.S. and in
all racial and ethnic groups, although the decrease was
most sizable among non-Hispanic whites (21%) and
least among non-Hispanic blacks (2%). Deaths declined
18% among men whose risk for HIV was homosexual
sex and 6% among intravenous drug users. Mortality
actually increased by 3% in women and people who
acquired HIV through heterosexual contact. Overall,
these new data add up to a substantial increase in the
national prevalence of AIDS, which has risen 10% since
1995 and 65% since 1993.
Comment: These figures echo data from New York
City and San Francisco. Many authorities are ascrib-
ing declining AIDS mortality to the potent antiretroviral
therapy now available, while others cite increased ac-
cess to medical care. In either case, the figures are
dearly cause for both celebration and concern, as the
increasing prevalence may soon strain both care and
prevention programs. - A Zuger
Update: Trends in AIDS incidence, deaths, and preva-
lence - United States, 1996. MMWR 1997 Feb 28; 46:165-73.
Reprinted by permission of Journal Watch, Volume
17, Number 7, April 1, 1997, issue. Copyright 1997. Mas-
sachusetts Medical Society.
CLIA Fact Sheets by Fax Program Expanded
by COLA and CDC
Five new Fact Sheets on CLIA regulations relating
to Proficiency Testing are immediately available free
of charge via same-day fax to physicians and their
staffs, because of an expansion of a cooperative agree-
ment between COLA and the Centers for Disease Con-
trol and Prevention (CDC). The Fact Sheets are avail-
able through cola's Customer Service Center at
800-298-8044.
"The response to the CLIA Fact Sheets by Fax pro-
gram has been phenomenal," says Douglas A. Beigel,
cola's Chief Operating Officer. "There have been
over 12,000 requests for the CLIA Fact Sheets by
576
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
healthcare professionals. Extending our cooperative
agreement with the CDC has enabled us to develop a
series of CLIA Fact Sheets on proficiency testing which
meets a strong need to provide brief, but comprehen-
sive information on this topic," Beigel says.
Initiated in 1995, the cooperative agreement be-
tween COLA and the CDC focuses on developing edu-
cational information to benefit physicians with office
laboratories. Prior to the new Proficiency Testing Fact
Sheets, COLA conducted an Educational Training
Needs Assessment of physician office laboratories and
produced a series of Fact Sheets on complying with
the Clinical Laboratory Improvement Amendments.
The single topic CLIA Fact Sheets condense infor-
mation from a variety of voluminous sources, such as
the Federal Register and laboratory manuals, into user
friendly, one and two page formats. There are 41 Fact
Sheets covering such topics as Quality Assurance,
Quality Control, OSHA, personnel standards as well
as Proficiency Testing. The complete list includes:
1. How to Register Your Laboratory for CLIA Purposes
2. How to Find Out More About Your Laboratory's
State Licensure Law
3. Seeking Accreditation from a HCFA-Approved Ac-
creditation Program
4. How to Properly Register Your Shared Laboratory
with HCFA
5. How to Get a Copy of the CLIA Regulations
6. Requirements for Provider- Performed Microscopy
Procedures
7. How to Change Your CLIA Certificate
8. Notification Requirements and Other Responsibili-
ties to HCFA
9. Writing a Procedure Manual
10. Proficiency Testing Information
11. What Every Laboratory Should Know About Docu-
mentation
12. Quality Control for Moderate Complexity Testing
13. Quality Control for High Complexity Testing
14. Remedial Actions
15. Quality Control for Microbiology
16. Quality Control for Hematology and Immunohe-
matology
17. Quality Control for Immunology
18. Quality Control for Mycobacteriology, Mycology,
and Virology
19. Quality Control Requirements for Blood Gas Analy-
sis and Drug Test Screening
20. A Possible Way to Manage Quantitative Quality
Control Results
21. Calibration and Calibration Certification Procedures
22. Safety Standards
23. OSHA Standards for Bloodborne Pathogens
24. Meeting the Personnel Standards for Moderate
Complexity Testing
25. Meeting the Personnel Standards for High Com-
plexity Testing
26. Grandfather Provisions for the General Supervisor
27. Responsibilities of the Laboratory Director
28. Grandfather Provisions for the General Supervisor
29. New Pathways to Qualify as the General Supervi-
sor and Testing Personnel for High Complexity Testing
30. Quality Assurance in the Laboratory
31. What to Expect During Your CLIA Inspection
32. How to Respond After Your On-Site Survey
33. CLIA Sanctions and Procedures for Appeal
34. List of CLIA Waived and PPM Tests
35. What to Expect During the Second Cycle Survey
36. HCFA Validation Survey Process
37. Enrolling in Proficiency Testing
38. Regulated Analytes
39. Proficiency Testing Providers
40. Proficiency Testing Paperwork
41. Evaluating Your PT Results
COLA is a non-profit, physician-directed organi-
zation whose purpose is to promote quality and excel-
lence in medicine and patient care through a program
of voluntary education, achievement and accreditation.
COLA was founded by the American Academy of Family
Physicians, American Medical Association, American
Society of Internal Medicine and the College of Ameri-
can Pathologists.
Now
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800-882-084 1
501-686-2592
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of Public Health & Tropical Medicine.
Volume 93, Number 12 - May 1997
577
Information on COLA's many additional physi-
cian and laboratory services, is available by calling
COLA at 800-981-9883.
Disciplinary Action Bulletin - Arkansas State
Board of Nursing
The nurses listed in this bulletin have had disci-
plinary action taken against their licenses. When a
nurse's license to practice nursing is revoked or sus-
pended, return of the license to the Board Office is
requested; however, licenses may not be returned.
Also, individuals placed on probation must continue
to meet conditions for the retention, or future rein-
statement, of their licenses. When hiring such an in-
dividual the Board Office should be contacted. There-
fore, the Board routinely suggests this list be shared
with the appropriate supervisory personnel and re-
cruiters in your organization. At the completion of the
disciplinary period, the nurse applies for reinstatement.
Reinstatement is contingent upon meeting the condi-
tions set forth by the Board.
In accordance with the Arkansas Nurse Practice
Act and the Arkansas Administrative Procedure Act,
the Arkansas State Board of Nursing took the follow-
ing action after individual hearings:
DISCIPLINARY: March 12, 1997
*Warren Jean Brown Jackson, LPN 13950 (North Little
Rock) Suspension - 2 years. Civil Penalty - $1,000.00
*Barbara Rene Rudd Johnson, RN 34675 (Springhill,
LA) Suspension - 3 years
*Cindy Paige Limbaugh, LPN 27878 (Newport) Allowed
to renew license followed by probation - 1 year. Civil
penalty - $750.00
^William Richard Donaldson, RN 36740 (Pocola, OK)
Consent agreement, 2 years probation, $500.00 civil
penalty
*Nancy Carol Sheets, RN 49957 (Hot Springs) Consent
agreement, 1 year probation, $500.00 civil penalty
^Kimberly Ouanda Bass, RN 50246 (Pine Bluff) Con-
sent agreement, 1 year probation, $500.00 civil penalty
^Pamela Lynn Simmons Kuyper, RN 31743
(Arkadelphia) Consent agreement, 1 year probation,
$500.00
*Donna Ellen Young, RN 29424 (Blytheville) Consent
agreement, 1 year probation, $250.00 civil penalty
^Christine Johnson, LPN 23873 (Prescott) Consent
agreement, 1 year probation, $500.00 civil penalty
DISCIPLINARY: March 13. 1997
*Lisa Anne Sullivan Hicks, RN 24568 (Little Rock) Li-
cense reinstated followed by revocation
*Rita Faye Cook Newman, RN 32513 (Hot Springs) Sus-
pension - 5 years
*Linda Jo Hankins Robinson, LPN 9209 (Rison) Sus-
pension - 5 years
“■Angela Yvette Jones Prater, LPN 30640 (Prescott) Pro-
bation - 1 year, civil penalty, $500.00
VOLUNTARY SURRENDER:
“^Brenda Ann Garner Cranford, RN 34749 (Ashdown)
*Cayce Jonette Asher-Griggs, LPN 31950 (Prairie Grove)
■^Emiley Anne Hilton Weedman, RN 25326 (El Dorado)
LETTERS OF REPRIMAND:
“Twanna Jean DeArmond Channer, LPN 35022
(Pocahontas)
“Hazel Louise Green Webb, LPN 18194 (Montrose)
“Vicki Sue Phillips Rhodes Holloway, LPN 34132
(Paragould)
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578 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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AMS Newsmakers
Dr. Donald B. Baker, a retired Fayetteville family
practitioner, is one of four recipients of the Washing-
ton Regional Medical Foundation's 1997 Eagle Award
for outstanding health leadership. This prestigious
award recognizes individuals and organizations that
have improved health care in Northwest Arkansas.
Former U.S. Sen. David Pryor, Ellen Meenen and the
St. Francis House Clinic were the other award win-
ners.
Dr. Jerry Hodges, a family practice physician in
Dardanelle, was recently elected president of the Yell
County Medical Society at the organization's annual
meehng.
Dr. Kevin Marty Hurlbut, a physician of physical
medicine and rehabilitation in Fayetteville, was recog-
nized recently by Northwest Arkansas Rehabilitation
Hospital - where he is medical director - for his leader-
ship and dedication to the facility.
Dr. F. Hampton Roy, of
Little Rock, has been elected
president of the American Col-
lege of Eye Surgeons. As presi-
dent, he will direct the
organization's activities, includ-
ing education programs related
to quality control in ophthal-
mology.
Dr. Dwight Williams, a
Paragould family practitioner,
has been reappointed by Gov.
Mike Huckabee to a three-year term on the state Board
of Health. His term will expire December 31, 2000.
The AMA Physician's Recognition Award is
awarded each month to physicians who have com-
pleted acceptable programs of continuing education.
Recipients are as follows: For the month of December:
Charles Watson Craft, Greenwood; Jimmie John Magie,
Conway; Shamim A. Malik, Pine Bluff; Michael Rich-
ard Platt, Gravette; and Victor Alan Rozeboom,
Harrison. For the month of January: Charles Marion Boyd,
Little Rock; Jerry Chalmas Chapman, Cabot; John
Sidney Elkins, Arkadelphia; Robert Lynn Fincher, Little
Rock; and David John Marzewski, Newport. For the
month of February: Donald Landers Cohagan,
Bentonville; James Toliver Crider, Harrison; Theophilus
A. Feild, Fort Smith; David Fried, Mena; Robert E.
Holder, Bentonville; Don Gene Howard, Fordyce; Gary
Michael Petrus, North Little Rock; Rheeta Minon
Stecker, Hot Springs National Park; Amy Simpson Tait,
Fort Smith; James Ray Weber, Jacksonville; and Morton
C. Wilson, Fort Smith. For the month of March: David L.
Baker, Conway; Roger Earl Cagle, Paragould; Wayne
Patrick Enns, Paris; Ziad Eskandar, Jonesboro; Stephen
Allen Hathcock, Little Rock; Connie Hiers, Jonesboro;
Kevin Martin Hurlbut, Fayetteville; Dale E. Johnston,
Little Rock; Robert Lee Kerr, Mountain Home; Hosea
W. McAdoo, Little Rock; Elvin Lloyd Norris, Beebe;
Norton Allen Pope, Little Rock; F. Hampton Roy, Little
Rock; Hoy Barksdale Speer, Stuttgart; and Joe Mitchell
Tullis, Mountain Home.
Send your accomplishments and photo for
consideration in AMS Newsmakers to:
Arkansas Medical Society
Journal Editor
PO Box 55088
Little Rock, AR 72215-5088
Freemyer Collection System, Inc.
Established 1941
"proven experts in
cash flow
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1-800-694-9288
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580
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
New Profile
ID
f J
George T. Gray, HI, M.D.
PROFESSIONAL INFORMATION
Specialty: General Practitioner
m I
Years in Practice: Ten years
Office: Conway
Medical School: Oklahoma State University College of Osteopathic Medicine, Tulsa, 1985
Internship: Harborside Hospital, St. Petersburg, Florida, 1986
Volunteer work: Lectures at the University of Central Arkansas and football physicals for Conway
Public Schools
Honors! Awards: President of the Arkansas Osteopathic Medical Association
PERSONAL INFORMATION
DatelPlace of Birth: July 4, 1958, in Conway
Children: Daughter, Ali, ten years old and Son, Tyler, eight years old
Hobbies: Running and horseback riding
THOUGHTS & OTHER INFORMATION
If I had a different job, I'd be: A triathlete
Best Habit: Exercising
Favorite junk food: Sweet tarts
Most valued material possession: My dogs, Wilbur and Abby
People who knew me in medical school, thought I was: Conceited
The turning point of my life was when: I became a father
Favorite vacation spot: Hawaii
One goal I haven't achieved, yet: Becoming a millionaire
One goal I am proud to have reached: Having two wonderful children
When I was a child, I wanted to grow up to be: A doctor
One of my pet peeves: Nagging
First job: Mowing lawns
Worst job: Welding
One word to sum me up: Compulsive
My philosophy on life: If you don't reach for it, you will never have it.
If you would like to appear in New Member
Profile or Member Profile, contact Tina Wade
at AMS at (501) 224-8967 or 1-800-542-1058.
Volume 93, Number 12 - May 1997
581
Special Article
The Patient-Physician Relationship:
Covenant or Contract?
James T.C. Li, M.D., Ph.D.
Many physicians are acutely aware of the external
forces that are threatening the medical profession. Most
of these forces are direct results of attempts to control
healthcare costs.
Although medical information science, quality
improvement, and practice guidelines all have the po-
tential to improve the quality of medical care, in prac-
tice, cost-containment strategies often ultimately de-
grade the patient-physician relationship. In some
managed-care settings, the clinical encounter is delib-
erately "managed"; thus, the physician's interests are
at odds with the patient's interests. Central to this
notion is the destruction of the traditional
patient-physician relationship in which the interests
of the patients come first. For example, in some
managed-care organizations, physicians are required
to sign a loyalty oath and gag order. The loyalty is to
the managed-care organization, and the gag order is
for patients. These orders prohibit or limit clinically
meaningful discussion with patients. When these rules
are coupled with payment schemes that reimburse
physicians to limit care, they dramatically undermine
the trust between the patient and the physician.
Managed-care organizations should not be blamed
for these cost-containment measures. After all, the di-
rectors of a for-profit corporation have a fiduciary duty
to put the interests of shareholders over their own
interests and the interests of their employees. The fi-
duciary relationship, between director and shareholder
or between a trustee and a beneficiary, is held to ex-
tremely high ethical standards. Executives in
managed-care corporations should not be criticized for
putting the needs of their stockholders first. In fact,
this fiduciary relationship should be supported and
honored.
Physicians, however, should be faulted for sub-
mitting to external pressures and for betraying the trust
granted to them by their patients. The relationship
between the patient and the physician is based on the
expectation that the physician will put the needs of
* Dr. Li is with the Division of Allergy/Outpatient, Infectious
Diseases and Internal Medicine, at Mayo Clinic Rochester, in
Rochester, Minnesota.
582
the patient first - over and beyond the interests of the
physician or any third party. This relationship is the
foundation on which the practice of medicine is built
and dates back to the era of Hippocrates and Asklepios
in ancient Greece (1,500 B.C. to 500 B.C.).’ The rela-
tionship between patient and physician should be held
to a standard at least as high as the fiduciary relation-
ship between director and shareholder.
Misplaced Priorities of Physicians. -Physicians have
not always upheld their responsibility to put the needs
of the patient first. The well-being of patients and the
profession of medicine have suffered when physicians
have put their own interests or the interests of a third
party before the interests of their patients. Greed, pres-
tige, and power have all succeeded at some time in
displacing patients as the top priority of physicians.
These lessons from history are relevant today.
When the pursuit of wealth or money becomes
the first priority of physicians in a fee-for-service envi-
ronment, patients may be subjected to unnecessary
diagnostic tests or therapeutic interventions. In a
capitated payment environment, concern about the
protection of the physician's own livelihood can lead
to withholding clinically needed care.
When the pursuit of fame or prestige becomes the
first priority of physician-investigators, patients may
undergo dangerous and life-threatening experimenta-
tion. The single-minded goal of scientific achievement,
even without the temptations of fame or prestige, can
be an equally false priority of physician-investigators.
The history of medical research during the current
century is riddled with examples of scientific miscon-
duct and ethical lapses. The infamous Tuskegee syphilis
study is but one example.
Patients, the medical profession, and society all
suffer when the interests of a third party become the
first priority of physicians. The third party can be the
physician's employer, a political party, or the govern-
ment. For example, physicians in the United States
have done harmful experiments with radiation and
toxic chemicals on unsuspecting persons for the ben-
efit of the government.
Extreme Incident of Physician Abuse of Power. -The
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
most horrific example of physicians' abandonment of
patients is the central role of physicians in the Third
Reich; after 1933 in Germany and 1938 in Austria, half
of all physicians were members of the Nazi partyT
Many of these physicians, often prominent in the aca-
demic community, were also leaders and perpetrators
of eugenics, euthanasia, and mass murder programs;
recall the image of the physician acting as gatekeeper
and triage officer at the concentration camps. Although
some physicians cried out against the pogroms, many
were silent. Others capitalized on employment oppor-
tunities made available by the disappearance of Jew-
ish physicians.^
Lessons for Today's Physicians. -Although no parallel
exists between physicians' behavior in the Third Reich
and physicians' behavior today, important lessons can
be learned by contemporary physicians. Dr. Jordan J.
Cohen discussed the conference entitled "Hippocrates
Betrayed: Medicine in the Third Reich" held on the
50th anniversary of the Nuremberg Doctor's Trial. The
conference "explored the antecedents of the contem-
porary relationship between physicians and the state
through an historical analysis of the roots of Nazi
medicine...." He declared that medicine can survive
and flourish only if physicians exercise constant vigi-
lance to ensure that medical science is used only for
service to humanity. This vigilance must include re-
sistance to the temptations of wealth, prestige, and
power. Some of the excesses previously described may
not have occurred if physicians had remembered their
obligation to put patients first and if they had had the
courage and strength to act on this principle.
Self-Examination. -In the spirit of such vigilance, I
suggest that each physician examine his actions by
addressing three questions.
1. Are you a caregiver or a gatekeeper? The caregiver
provides care and concern to a person in need, heal-
ing if possible, helping always. To sick persons, the
caregiver is "a guide through some of life's most diffi-
cult journeys."^ In contrast, the gatekeeper minds the
gate, letting some persons through and keeping oth-
ers out. The function of the gate is to restrict access.
The gatekeeper serves the interests of the owner of
the gate not of the people trying to get through the
gate. Physicians are just beginning to realize that the
gatekeeper serves entirely at the whim of the owner
of the gate.
2. Which principle governs your relationship with the
patient: Morality or the marketplace? The term "moral-
ity" refers to the basic human concept of right and
wrong. For physicians, morality means doing what is
right for our patients and speaking or acting out against
what is wrong. No such moral absolute can be found
in the marketplace. The market is driven by revenue,
profit margins, and market share. No patients exist in
a market-driven practice of medicine - only consum-
ers for whom the watchword is caveat emptor.
A great danger to the practice of medicine is the
transformation of physicians to interchangeable, dis-
pensable workers accountable only to their employers
and the financial performance of the institution that
employs them. In this setting, physicians and health
care are simply commodities - cold and without com-
passion. The greatest danger, however, is not loss of
the physician's autonomy, degradation of the profes-
sion of medicine, or transformation of health care to a
commodity. The greatest danger is the transformation
of the patient to the status of commodity. The lessons
from history are particularly instructive on this point.
In the Hippocratic model of medicine, the patient
represents a vulnerable person in need - the first and
only priority of the physician. In the commercial model
of medicine, the patient is at best a consumer: at worst,
the patient is a source of revenue when well and a
source of medical (financial) losses when sick. In a
capitated, commercial system, physicians and
managed-care organizations have every financial rea-
son to shun sick people. In this system, physicians
make economic (not clinical) decisions and provide
medical explanations for those decisions. Patients are
left to fend for themselves and to face the consequences
alone.
3. What is the relationship between you and your pa-
tient? Is it a covenant or a contract? A group of clinical
ethicists defined the practice of medicine as "a moral
enterprise grounded in a covenant of trust. "^Webster's
Ninth New Collegiate Dictionary defines covenant as
a "formal, solemn, and binding agreement." For a more
complete understanding of the term "covenant," we
must return to our professional ancestors in ancient
Greece. During the time of Hippocrates, the Greek
term for covenant (diatheke) was not used to describe
a usual agreement or contract between two parties.
The term "diatheke" was used almost exclusively to
signify a very special relationship - a will and testament.
A last will and testament involves parties who have
a special and close relationship with each other; a con-
tract involves strangers. A last will and testament is
based on trust; a contract is based on mistrust. A last
will and testament is a relationship between two un-
equal parties in which one party is concerned about
the welfare of the other. A contract is between two
equal parties, each concerned only with his own wel-
fare. In its essence, a will and testament is a benefi-
cent promise, a trust offered by one party to another.
For physicians, this promise is to put the interests and
needs of the patient first. The term "covenant" aptly
describes the relationship between patient and physi-
cian. Physicians should have the conviction and cour-
age to defend this covenant not only against external
threats but also against internal threats of fear, igno-
rance, and complacency.
Address reprint and reference requests to Dr. J. T. C. Li,
Division of Allergy, Mayo Clinic Rochester, 200 First Street SW,
Rochester, MN 55905.
Reprinted with permission of the Mayo Foundation for Medical
Education & Research, from Mayo Clinic Proceedings, 1996; 71:917-8.
Volume 93, Number 12 - May 1997
583
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584 JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
I
— — L
Investments
INVESTMENT ADVICE
Who Do You Call?
Larry Waschka
When I was growing up in a small town in Arkan-
sas, everyone knew where the local doctors lived be-
cause their houses were always the biggest and nic-
est. Back then, if you were a doctor, you were almost
guaranteed a wealthy lifestyle. But now things have
changed. A study done in 1994 showed that the aver-
age yearly income for a physician in private practice
was $218,000. That may seem high to some people,
but relative to the corporate CEO, it seems quite low.
The average total compensation of America's 100 high-
est paid CEOs was $3,554,000 which included bonuses
and stock options. This is 190 times the average Ameri-
can worker's income.
With the advent of HMO's and other sweeping
changes in the medical field, a physician's income no
longer means that financial security is guaranteed. I
have many clients who are physicians, and 1 hear their
fears about declining salaries and what the future holds.
One physician in particular made a very good anal-
ogy. He had performed a lot of financial calculations
for his practice and said that he had to work Monday,
Tuesday, and Wednesday of every week just to cover
his overhead. The remaining two days he made a
profit. His point was that if he took a day off during
the week, he lost half of his profit. Taking off one day
or even just an afternoon was a weekly "catch 22."
He wants to retire comfortably, but, with less con-
trol over his profitability, he's left with only a handful
* Larry Waschka, a registered investment advisor, is the presi-
dent of Waschka Capital Investments, an independent fee-based
investment advisory firm managing over $80 million in assets.
He is author of The Complete Idiot's Guide to Getting Rich
and has been quoted in L.A. Times, Your Money Magazine,
Kiplingers, Mutual Fund Market News, and Financial Planning
Magazine. He recently appeared on the national programs CNN
Financial News and MS-NBC.
of things he can do. He could reduce his expenses
and save more, but that's easier said than done. The
net result is that he came to me looking for answers.
His primary concern became portfolio return— he
thought, if 1 can't control the profitability of my prac-
tice, why not work on the performance of my portfolio.
Now, more than ever, you must be a good money
manager in order to have a secure retirement. A se-
cure financial retirement consists primarily of a port-
folio large enough to produce an income stream suffi-
cient to cover your living expenses and other addi-
tional expenditures for such things as travel.
How much is enough? Let's take a basic example.
Assume that you want an annual after tax income of
$100,000 at age 65. If you assume a 40% tax bracket,
that figure becomes $166,666 before tax.
If you were able to get a 10% return on your port-
folio, your portfolio would have to be worth at least
$1,666,666 just to cover your income.
However, if you were able to get a 13% return,
you would only need $1,282,046 in your portfolio.
That's a difference of $384,620 which is a lot of money.
This just reminds us how very important portfolio re-
turn is at this stage of the game.
Let's look at this another way. At the age of 40,
how much would you have to save each year to retire
at 65 with a portfolio of $ 1,666,666? The answer again
depends upon your portfolio return. At a compounded
10% return (tax deferred), you would have to save
$1,284 per month. However, given a 13% return, you
would only have to save $789 per month. I don't want
to encourage anyone to save less— I just want to again
point out the importance of portfolio return on your
investments especially during the savings years.
When looking at a long-term picture, just a couple
of percentage points can make a big difference in how
Volume 93, Number 12 - May 1997
585
you will live in retirement. The first question you must
ask yourself is, "Do I have the time and the interest to
manage my money?" Certainly, there are plenty of
professionals who do. The second, but equally impor-
tant, question is, "Could I do as well as a professional
money manager, net of fees?" If the answer to either
of these questions is no, then you should consider
hiring professional help.
So let's say you need help. Who do you call? What
questions should you ask? How much time will all
this take? Well, not much if you know what you want.
If you really want someone to manage your money
for you, who has no incentive to sell you anything for
a commission, you need to consider hiring an inde-
pendent fee only manager. Because their annual fee is
based upon a percentage of the amount of assets they
manage for you, there is no conflict of interest. The
fee-only arrangement not only motivates the manager
to make you as much money as he/she can, it also
motivates them to save you money on transactions.
Look in the phone book under "Investment Advisors"
and call several of them.
First, ask if they are fee-only. If they say they are
fee and commission based, tell them, "no, thank you."
Conflicts of interest still exist in this arrangement. Sec-
ond, ask how long the advisor has been in the invest-
ment industry. A ten-year veteran experienced the 1987
crash, the 1990 correction, and the hey days of '95 and
'96. You may also want to ask about the depth of the
advisor's staff. How much experience do they have?
How many registered investment advisors work there?
Third, ask how much money they have under man-
agement. Any manager with $25 million or more un-
der management should be considered. Fourth, ask
about their track record. How well did they do last
year? How well did they do in 1994 (a very tough year)?
Fifth, ask who makes the investment decisions. Some
managers base all their decisions on an investment
newsletter so they can use their performance figures.
One last thing--ask for a list of client references.
Call a few and ask them about the advisor's service,
performance, and integrity. Ask them what they like
about the advisor and what they dislike. This conver-
sation will tell you a lot.
In the end, you need to be comfortable with the
advisor you select. The only way to achieve this com-
fort is to do a little homework. If you'll take the time
to find the right advisor, your portfolio will have more
potential for exceeding your expectations. Plus, you
might even sleep better.
CALL TODAY
Ask for Craig to get your
FREE PRIMARY CARE INFO PACK
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586
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Loss Prevention
A Good History Usually Gives a Diagnosis
J. Kelley Avery, M.D.*
Case Report
At 3:00 a.m. abdominal pain and vomiting began.
At 4:30 a.m. she was seen by the emergency depart-
ment (ED) physician, who discharged her at 6:30 a.m.
Thirty hours later she was returned to the ED in car-
diorespiratory arrest and died following an emergency
laparotomy. She was 22 years of age!
When the patient was seen on admission to the
ED, the history was recorded by the ED physician:
"Abdominal pain since 3:00 a.m. Vomited two times.
Normal BM yesterday. No flatus since onset. Men-
strual history normal." Examination: "22-year-old
woman appears in pain. VS normal. Chest, heart, lungs
OK. Abdominal tenderness, lower abdomen, but no
guarding or rebound. Less tenderness mid-abdomen.
Bowel sounds positive."
Laboratory studies were unremarkable except for
a blood glucose of 194 mg/dl.
Nursing note at 4:30 a.m.: "Alert and oriented.
Appears in pain. Rolling around on the stretcher.
Medicated for pain. Sleeping since. The record indi-
cates that she was given Talwin 30 mg and Phenergan
25 mg by injection at 5:50 a.m. Discharged home with
instructions at 6:35 a.m." She was given an antacid/
antispasmodic and Phenergan suppositories for use at
home. She was told to return to ED if further prob-
lems occurred "this weekend."
The narrative is blank until she returned "this
weekend" 30 hours after leaving the ED. CPR was in
progress when the patient arrived. She was resusci-
tated, hydrated, acidosis corrected, and taken to the
OR, where strangulated, infarcted small bowel was
found to have herniated through a defect in the me-
sentery. The dead bowel was resected, but despite
vigorous and heroic efforts, the patient died about 6:00
p.m., four hours after surgery.
In the lawsuit that followed, the physician was
charged with failure to take an adequate history and
do a thorough physical examination, failure to moni-
tor adequately in the ED, and failure to use appropri-
ate testing to determine the true nature of her com-
plaints. Going to trial with a record as incomplete as
* Dr. Avery is Chairman of the Loss Prevention Committee,
State Volunteer Mutual Insurance Co., Brentwood, TN. This
article appeared in the April 1995 issue of the Journal of the
Tennessee Medical Association. It is reprinted with permission.
this one was considered unwise, and the case was
settled.
Loss Prevention Comments
The loss prevention lesson to be learned here can
be derived from the charges filed against this ED phy-
sician. There was ample evidence that the doctor did
not get a good history. He missed the significance of
the sudden onset of severe pain and the prompt vom-
iting that followed. He made no comment as to the
apparent severity of the pain. He recorded "No flatus
since onset." The nurse, in her note two hours before
the patient was discharged from the ED, noted that
the patient was in pain severe enough to cause her to
roll around on the table and to need the side rails to
keep her on the stretcher. There was no note that the
patient was re-evaluated by the ED physician in view
of these findings. In fact, there was no evidence in the
record that the patient was checked at all from the
time of her initial examination to the time of her dis-
charge except to administer the injection. This gave
validity to the charge of failure to adequately monitor
the patient in the ED.
The initial examination was brief as far as the record
is concerned. No pelvic examination was done even
though it is apparent that the physician was careful to
obtain an acceptable menstrual history. One wonders
if the doctor put his hand on this young woman's
abdomen or listened to the bowel sound after the ini-
tial examination. As rapidly as this patient's condition
was deteriorating, it is reasonable to speculate that
had careful monitoring been done, the bowel sounds
would have been found hyperactive, and the abdo-
men itself would have been more generally tender with
some distension, suggesting the need for an abdomi-
nal x-ray.
We had no diagnosis when a narcotic was given to
relieve the symptoms, which, if carefully observed,
would have led to the suspicion of a rapidly progress-
ing process demanding early exploration of the abdomen.
It was the weekend, the ED was busy, and the
tendency was, as it frequently is, to bet on the "odds"
and not think about the "long shot." Almost every
time, when confronted by a patient with an acute prob-
lem, a physician needs to prepare for the worst while
hoping for the best.
Volume 93, Number 12 - May 1997
587
Medicare Post Pay Review Audits
Effective January 1 , 1997, the federal government will step up their efforts to identify
CODING VIOLATIONS AND CONSIDER FRAUD AND ABUSE CHARGES AGAINST PHYSICIANS.
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EMERGENCY
MEDICINE
Emergency Medicine, anew feature section in The Journal, will appear quarterly. Send your comments and/or contributions to The Journal 's
editorial office.
Delayed cardiac tamponade
following a stab wound: a case report
Jerel Lee Raney, M.D.*
Elicia Sinor Kennedy, M.D.**
Abstract
Penetrating trauma is a frequent presentation to
urban emergency departments (EDs). Pericardial effu-
sion with cardiac tamponade is a possible complica-
tion of penetrating trauma to the chest, to the back,
and to the upper abdomen. Even if patients are stable
initially without signs or symptoms of cardiac tam-
ponade, there can be delayed sequelae. Presented is a
case of cardiac tamponade diagnosed 21 days after a
stab wound to the epigastrium.
Introduction
Penetrating chest trauma with cardiac injury is
associated with pre-hospital mortality rates between
29 and 83 percent.’ Of those that do arrive to the ED
alive, 80-90 percent of stab wounds will demonstrate
cardiac tamponade.^ Classically, the triad of muffled
heart sounds, hypotension, and distended neck veins
has been used to make a clinical diagnosis of cardiac
tamponade.’ When central venous monitoring and
continuous cardiac monitoring are utilized, a rise in
central venous pressure along with tachycardia are the
most reliable signs of cardiac tamponade.’ In addition,
pulsus paradoxus (a drop in systolic blood pressure
greater than 10 torr on inspiration) and electrocardio-
gram (ECG) changes (electrical alternans, low QRS
voltage) are sometimes present. Even if none of the
above signs are present at initial presentation or dur-
ing hospitalization there still must be a high index of
suspicion for cardiac injury with penetrating chest,
back, and upper abdominal trauma. We present the
case of a 35 year old male initially asymptomatic with-
out signs or symptoms of cardiac injury following a
stab wound to the epigastrium. He presented 21 days
later with pericardial tamponade.
* Dr. Kennedy is Assistant Professor, UAMS, Department of
Emergency Medicine.
Dr. Raney is a second year resident at UAMS, Department
of Emergency Medicine.
Case Report
A 35 year old black male was stabbed in the chest
during an altercation. The knife was reportedly six to
seven inches long. After initial stabilization at an out-
side facility, he was transferred to our hospital. At the
outside facility laboratory, values drawn showed a he-
matocrit (HCT) of 32 percent, and a hemoglobin (Hgb)
of 11.0 gm/dl. The patient remained stable during trans-
port. On arrival to our ED, the patient was alert and
oriented, complaining only of pain at the site of the
stab wound. He had no significant past medical his-
tory and was taking no medications. Physical exami-
nation revealed a well developed, well-nourished black
male in no acute distress. Vital signs were as follows:
pulse 80/min, blood pressure (BP) 120/72 mm Hg, res-
piratory rate (RR) 22/min, oxygen saturation (O^ Sat)
99% on 2 liters oxygen by nasal canula, temperature
98.9. Head, ears, eyes, nose and throat examinations
were unremarkable. There was no jugular venous dis-
tention (JVD). Lungs were clear bilateral and heart
tones were easily audible without murmur or rub.
There was a 2 cm stab wound to the left of the xiphoid
process, with no active bleeding. The abdomen was
non-tender, non-distended and there were active bowel
sounds. Rectal examination was negative for occult
blood, as was a naso-gastric aspirate. Pulses were eas-
ily palpable in all extremities. Chest x-ray (CXR)
showed a normal cardiac silhouette without pneu-
mothorax or hemothorax (figure 1). Abdominal x-ray
was negative for air/fluid levels or free air. A bedside
echocardiogram (ECHO) done in the ED revealed no
pericardial fluid and normal cardiac wall motion. Labo-
ratory values drawn at our institution were as follows:
white blood count (WBC)- 18.6 K/ul, HCT-33.7 per-
cent, Hgb-11.3 gm/dl, platelets- 252,000.
The patient was admitted to the trauma surgery
service. Serial hematocrits were obtained and serial
Volume 93, Number 12 - May 1997
589
Figure I: Portable chest x-ray at initial Figure 2: Portable intra-operative chest x-rays
presentation
abdominal examinations were performed. His HCT
remained stable and his abdomen remained
non-tender. In addition he showed no clinical signs or
symptoms of pericardial tamponade. Echocardiogram
and CXR were not repeated. He was discharged 24
hours after admission.
Twenty-one days after his initial hospitalization the
patient was taken to an outside hospital. He com-
plained of weakness, diaphoresis, shortness of breath,
and a syncopal episode on the day prior to presenta-
tion. He had been complaining of general malaise since
his discharge, with the symptoms worsening acutely.
Initial work-up prior to transfer included a chest x-ray
that showed an enlarged cardiac silhouette and bilat-
eral pleural effusions. ECG monitoring revealed sinus
tachycardia and non-specific T-wave abnormality. A
large pericardial effusion with cardiac tamponade was
seen on ECHO. The patient received a 1 liter fluid
bolus and was transferred to our ED. On arrival, physi-
cal examination revealed a well-developed male in
moderate respiratory distress. Vital signs were:
Pulse-125/min, BP-118/85, RR-26. Physical examination
was significant for JVD to the angle of the jaw, de-
creased breath sounds at the lung bases bilaterally,
and distant heart tones without audible murmur or
rub. The abdomen was diffusely tender. Rectal exami-
nation was normal. A repeat chest x-ray showed an
enlarged cardiac silhouette and small pleural effusions
(Figure 2- intra-operative). A repeat echocardiogram
confirmed right atrial and right ventricular diastolic
collapse with a large pericardial effusion. Laboratory
studies showed; WBC 11.5K/ul, Hgb-7.6 gm/dl,
590
HCT-23.0%, Platelets-533,000.
The patient was taken to the operating room where
an exploratory laparotomy was performed through a
sub-xiphoid incision. Abdominal exploration revealed
a markedly enlarged liver and no intra-abdominal in-
jury. The pericardium was opened and one liter of
clotted and fresh blood was aspirated. No evidence of
a cardiac wound was reported in the operative note.
A right angle chest tube was placed in the mediasti-
num to drain the pericardium. The postoperative
course was remarkable only for one episode of in-
creased temperature and elevated WBC, both of which
resolved and blood and urine cultures were negative
for growth. The patient had no further complaints of
shortness of breath. Serial CXRs showed no increase
in sized of the cardiac silhouette. A repeat ECHO on
the day prior to discharge showed no reaccumulation
of fluid. The patient was discharged on post-operative
day 6. He returned 10 days after discharge for a
follow-up ECHO which was negative.
Discussion
It is generally agreed that an unstable patient with
penetrating chest trauma should undergo ED thorac-
otomy with rapid transfer to the operating room.’
However, there has been much debate regarding the
initial approach to the stable patient without signs or
symptoms of cardiac injury.^ ’®
Early surgical intervention has been advocated for
the stable patient.'’'^ * It has been shown that patients
without signs or symptoms of cardiac tamponade could
have occult cardiac injury.* An aggressive surgical approach
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
could potentially eliminate the rare, but important,
delayed sequelae from missed cardiac injury.*
Pericardiocentesis, long used to diagnose and treat
pericardial tamponade, has previously been recom-
mended as part of the initial management of penetrat-
ing chest trauma.^ Although a rapid procedure which
can provide quick results, pericardiocentesis is associ-
ated with a high false negative rate in cases subse-
quently shown to have blood in the pericardium.'’ This
is thought to be due to the inability to aspirate clotted
blood.
Two-dimensional thoracic echocardiography done
in the ED is becoming the modality of choice in evalu-
ating the heart and pericardium in penetrating chest
trauma.’® ’* It is non-invasive and can be done rapidly
at the bedside. Nagy et al” reviewed the charts of 121
patients with penetrating chest wounds. Thirty-one
patients had a positive ECHO, sixteen of whom had
pericardial blood confirmed with sub-xiphoid pericar-
dial window. One patient with a negative ECHO sub-
sequently deteriorated, with a repeat ECHO five hours
later positive for pericardial effusion. ECHO has been
shown to decrease time to diagnosis in penetrating
cardiac injury when used as an early diagnostic tool.
Freshman et al’^ found ECHO to be a useful triage
tool, with patients having small pericardial effusions
being admitted to ward beds and monitored without
adverse outcome.
Bolton et al’* demonstrated that a negative
echocardiogram does not rule out occult cardiac in-
jury. In his study, he presented five patients with pen-
etrating cardiac trauma, all of whom underwent
echocardiography. Two of the patients had negative
initial ECHOs, but all five had major intrapericardial
injuries.
Chest x-ray findings are unreliable in the diagno-
sis of pericardial effusion at initial presentation.’* Rarely
does one see the classic enlarged silhouette seen in
chronic tamponade. In addition, ECG findings are in-
sensitive in diagnosing pericardial effusions.^ Physical
examination findings of tamponade may not be present
initially, even after fluid resuscitation.’
Delayed pericardial tamponade is a rare phenom-
enon in penetrating chest trauma, with less than ten
cases in the medical literature. The majority of experi-
ence with delayed cardiac tamponade comes from open
heart surgery. Maronas et aP'* reported on 21 patients
who developed delayed cardiac tamponade after sur-
gery. In these patients, clinical suspicion and
echocardiography were shown to be the most reliable
methods of diagnosis. The experience from open heart
surgery is relevant to this case as stab wounds are
similar to surgical incisions in the myocardium, and
the clinical presentation of delayed tamponade is likely
to be similar.’
The debate regarding the initial work-up of pen-
etrating chest trauma will likely continue. In our case,
the initial echocardiogram was negative for effusion,
and the patient exhibited no signs or symptoms of
cardiac tamponade. Only emergent operative interven-
tion could possibly have detected the occult injury.
However, the effusion may have been detected earlier
with a repeat echocardiogram prior to discharge or
very soon afterwards as an outpatient. This case dem-
onstrates that one must have a high index of suspi-
cion for cardiac injury in all cases of penetrating chest
trauma.
References;
1. Karrel R, Shaffer KR, Franaszek JB: Emergency di-
agnosis, resuscitation, and treatment of acute penetrat-
ing cardiac trauma. Ann Emerg Med 1982;11:504-516.
2. Borja AR, Lansing AM, Ransdell HT Jr: Immediate
operative treatment for stab wounds of the heart; ex-
perience with 54 consecutive cases. / Thorac Cardiovasc
Surg 1979;59:662-667.
3. Sharp JR: Hemodynamics during induced cardiac
tamponade in man. Am ] Med 1960;29:640-646.
4. Meyers DG, Bag in RG , Lenvene J F: Electrocardio-
graphic changes in pericardial effusion. Chest
1993;104:1422-1426.
5. Sugg WL, Rea WJ, Ecker RR: Penetrating wounds
of the heart-an analysis of 459 cases. / Thorac Cardiovasc
Surg 1968;56:531-543.
6. Andrade-Alegre R, Mon L: Subxiphoid pericardial
window in the diagnosis of penetrating cardiac trauma.
Ann Thor Surg 1994;58:1139-1141.
7. Bolanowshi P, Swaninathan AP, Nexille WE: Ag-
gressive surgical management of penetrating cardiac
injuries. / Thorac Cardiovasc Surg 1973;66:52-57.
8. Klinkenberg TJ, Kaan G L, Lacquet LK Delayed se-
quelae of penetrating chest trauma: a plea for early
sternotomy. / Cardiovasc Surg 1994;35:173-175.
9. Breaux EP, Dupont JB, Albert HM et al: Cardiac
tamponade following penetrating mediastinal injuries:
Improved survival with early pericardiocentesis. J
Trauma 979;19:461-466.
10. Plummer D, Brunette D, Asinger R et al: Emer-
gency department echocardiography improves out-
come in penetrating cardiac injury. Ann Emerg Med
1992;21 :709-712.
11. Nagy KK, Lohmann C, Kim DO et al: Role of
echocardiography in the diagnosis of occult penetrat-
ing cardiac injury. / Trauma 1995;38:859-862.
12. Freshman SP, Wisner DH, Weber CJ: 2-D
echocardiograph: emergent use in the evaluation of
penetrating precordial trauma. / Trauma
1991;31:902-905.
13. Bolton JW, Bynoe RP, Lazar HL, et al:
Two-dimensional echocardiography in the evaluation
of penetrating intra-pericardial injuries. Ann Thorac Surg
1993;56:506-509.
14. Maronas JM, Otero-Coto E, Caffarena JM: Late car-
diac tamponade after open heart surgery. /
Cardiovasc. Surg 1987;28:89-93.
Volume 93, Number 12 - May 1997
591
Cardiology Commentary and Update
Pius Manavalan, M.D.*
Derrick Richardson, M.D.*
Richard Rayford, M.D., Ph.D.**
J. David Talley, M.D.**
ECG and Cardiac Enzymes Changes
Associated with Subarachnoid Hemorrhage
An acute cerebrovascular event, especially sub-
arachnoid hemorrhage, may cause changes in the elec-
trocardiogram (ECG) and cardiac enzymes diagnostic
of an acute myocardial infarction (MI). We report a
patient who sustained a massive subarachnoid hem-
orrhage who had ECG changes and elevated cardiac
enzymes consistent with a non-q wave MI.
Patient Report
A 47-year-old female with a history of systemic
arterial hypertension (Table 1, Complete Problem List)
was admitted to the Neurosurgery Service with the
sudden onset of a severe occipital headache associ-
ated with altered mentation. The patient did not have
a history of myocardial ischemia or infarction.
The ECG showed ST segment elevation and T wave
inversion in leads V^-V^ (Eigure 1). Serial cardiac en-
zymes had a rising trend, peaking at 985 U/L, with an
MB fraction peak of 25.2 (Table 2). A diagnosis of a
non-q MI was made and patient was placed on telem-
etry monitoring and begun on heparin, captopril,
atenolol, and nimodipine.
A cranial CT scan revealed a massive subarach-
noid hemorrhage. A cerebral angiogram showed mul-
tiple aneurysms and diffuse vasospasm. She was con-
sidered to be at a prohibitively high risk for surgical
intervention and intra-arterial GDG coils were inserted
at the site of the intracranial bleeding. The patient con-
dition continued to deteriorate and she expired on the
5th hospital day. A post-mortum examination was not
obtained.
Pathophysiology of the Cerebral-Induced
Myocardial Necrosis
The autopsy examination of patients who succumb
to an acute cerebral event, as our patient did, frequently
* Drs, Manavalan and Richardson are with the Department of
Internal Medicine at UAMS.
** Drs. Rayford and Talley are with the Division of Cardiology at UAMS.
shows sub-endocardial or scattered myocardial necro-
sis, without extensive coronary artery disease or trans-
mural myocardial necrosis.^ An acute cerebral vascu-
lar event may cause hypothalamic dysfunction or hem-
orrhage thereby increasing the level of circulating cat-
echolamines. Similar changes are seen in
hyperadrenergic animals and in patients with a pheo-
chromocytoma.^ These changes can be reproduced by
experimentally stimulating the posterior-lateral hypo-
thalamic centers in the brain responsible for autonomic
regulation.'^
The heightened autonomic tone may lead to focal
myocardial necrosis in multiple ways. First, the el-
evated blood pressure increases wall tension potenti-
ating endothelial cell ischemia. Secondly, the elevated
catecholamine levels may decrease myocardial oxygen
supply by causing coronary artery vasospasm." Finally,
catecholamines may act as a direct toxin to the indi-
vidual myocardial cells. Other mechanisms contribut-
ing to myocardial necrosis include electrolyte imbal-
ance, hypercortisolism, vagal dysregulation and acti-
vation of the renin-angiotension system."
The Spectrum of Cardiac Abnormalities
The Electrocardiogram. ECG changes are seen in
20-80% of patients with a cerebrovascular accidents. ®
These changes are most frequently seen in patients
with subarachnoid hemorrhage, intracerebral hemorrhage.
Table 1; Complete Problem List
1. Systemic arterial hypertension
2. Subarachnoid hemorrhage
3. Myocardial disease
Etiology -> subarachnoid hemorrhage
Anatomy -> unknown
Physiology non-Q wave myocardial infarction
Objective assessment -> unknown
Functional capacity -> unknown
592
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Table 2: Serial Changes in the Total and Iso-enzymes of
Creatine Kinase
Hospital Day
CK
(30-235 U/L)
CK-MB
(0-7.2 U/L)
RI
(0-2.5)
Day 1
436
20.7
4-7
Day 2
812
25.2
3.1
Day 2
985
17.9
1.8
Day 3
866
16.5
1.9
Day 3
797
14.4
1.8
Day 4
802
15.7
2.0
Day 4
802
10.1
1.3
Day 5
788
7.0
0.9
Abbreviations: CK = creatine kinase, RI = relative index
and suspected cerebral embolism with infarction. Simi-
lar changes may be seen in a patient who has sus-
tained a severe head injury or those who have a
space-occupying lesion.
The classic ECG pattern of cerebrovascular acci-
dent is the triad of deep T wave inversions, prominent
U waves, and marked prolongation of the QT inter-
val. These changes have been coined the "CVA T leave
pattern.'"^ The T wave inversion is striking. They have
widely splayed arms and are blunted at the nadir.
Occasionally the T waves are so wide that they sub-
tend the entire ST interval. This is in contrast to the
narrower, sharply inscribed, relatively symmetric T
wave inversion characteristic of an MI. These differ-
ences however are not absolute.
Marked prolongation of the corrected QT interval
often with prominent U waves may also be seen. The
U waves may be buried within the T wave, giving it
an irregular appearance. Prolongation of the QT inter-
val with T wave inversion are also seen in MI but rarely
to the degree seen with an acute cerebrovascular event.
New Q waves are not commonly seen in patients
with a primary neurological event. Interestingly, pa-
tients who evolve new Q waves do not develop the
deep T wave inversions. There are, however, reports
of new Q waves without autopsy evidence of trans-
mural infarction. Other common ECG findings include
a variety of bradyarrythymias and tachyarrythymias
and ST segment depression or elevation.
Cardiac Enzymes. Cardiac enzymes are elevated in
approximately 50% of patients with an acute cere-
brovascular event.’ The total creatinine kinase and the
CK-MB are both increased, and the time course of the
elevation is similar to that seen with an acute MI. A
higher rate of mortality is observed in patients with an
acute cerebral event who have both ECG changes and
elevated cardiac enzymes.’®
Echocardiogram. Abnormalities seen in the
echocardiogram and left ventriculogram include tran-
sient global or segmental hypokinesis or akinesis. Mural
thrombi have also been reported. The degree of car-
diac dysfunction is closely as-
sociated with the severity of
the subarachnoid hemor-
rhage.”
Conclusions
An acute cerebrovascular
disorder, notably subarach-
noid hemorrhage, frequently
cause ECG changes and el-
evated cardiac enzymes con-
sistent with an acute MI. At
autopsy, these changes have
not been generally associated
with transmural infarction or
pathologically significant coro-
nary artery disease. A higher
rate of mortality is observed in patients who have both
ECG changes and elevated cardiac enzymes.
Yir
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Figure 1: The 12 lead electrocardiogram shows normal si-
nus rhythm, ST segment elevation, and deep T wave in-
version in leads I, VL, and V -V,
'a ' 1 6
References
1. Duren DR, Becker AK. Focal myocytolysis mimicking the elec-
trocardiographic pattern of transmural anteroseptal myocardial in-
farction. Chest 1976;69: 506-511.
2. Talley JD. Pheochromocytoma. In: Talley JD, ed. Cardiovascular
Involvement in Systemic Diseases, Philadelphia, PA: Williams &
Wilkins, 1997:27-31.
3. Pine DS, Tierney L Jr. Clinical problem-solving: A stressful inter-
action. N Engl J Med 1996; 334:1530- 1534.
4. Yuki K, Kodama Y, Onda J, Emoto K, Morimoto T, Uozumi T.
Coronary vasospasm following subarachnoid hemorrhage as a cause
of stunned myocardium. J Neurosurg 1991:75:308-311.
5. Goldberger AL . Deep T wave inversions: noninfarctional causes
associated with cerebrovascular accident and related patterns. In:
Goldberger AL. Myocardial Infarction: electrocardiographic differ-
ential diagnosis, 4th ea., St. Louis, MO. Mosby Year Book, 1991;
291-305.
6. Brouwers PJAM, Wijdicks EFM, Hasan D, Vermeulen M, Wever
EFD, Frericks H, van Gijn J. Serial electrocardiographic recording
in subarachnoid hemorrhage. Stroke 1989:20:1162-1167.
7. Hammermeister KE, Reichenbach DD. QRS changes, pulmonary
edema, and myocardial necrosis associated with subarachnoid hem-
orrhage. Am Heart J 1969; 78: 94- 100.
8. Diamond T, Segal F. Subarachnoid hemorrhage masquerading
electrocardiographically as acute myocardial infarction. Heart Lung
1984; 13:451 -453.
9. Hunt D, McRae C, Zapf P. Electrocardiographic and serum en-
zyme changes in subarachnoid hemorrhage. Am Heart J
1969:77:479-488.
10. Kaste M, Somer H, Konttinen A. Heart type creatine kinase
isoenzyme (CK MB) in acute cerebral disorders. Br Heart J
1978;40:802-805.
11. Pollick C, Cujec B, Parker S, Tator C. Left ventricular wall mo-
tion abnormalities in subarachnoid hemorrhage: an
echocardiographic study. J Am Coll Cardiol 1988:12:600-605
Volume 93, Number 12 - May 1997
593
StAtc Hakh WAtcl
1
Information provided by the Arkansas Department of Health, Division of Epidemiology
Methyl Parathion Facts: A Physician Resource
Methyl parathion, also known as "cotton poison,"
is an organophosphate insecticide intended for use on
cotton, soybeans and other crops. An insecticide, it
should be used only in open fields to control insects.
It is used on cotton, soybeans, and vegetable fields in
the South.
Methyl parathion has been illegally used as a pes-
ticide for control of cockroaches and other household
pests in some homes, businesses and day care centers
in Mississippi, Louisiana and Tennessee. In Arkan-
sas, methyl parathion was reportedly used in homes
in the West Memphis area and possibly other loca-
tions in eastern Arkansas.
Indoor use of this chemical can cause severe health
problems. The main routes of exposure are ingestion
and dermal contact. Immediately after spraying, inha-
lation might also be a significant source of exposure.
Symptoms
Severe poisoning will lead to salivation, "pinpoint
pupils," blurred vision, bradycardia, muscle fascicula-
tion, diarrhea and altered mental status - irritability or
lethargy. Less severe poisoning can cause headaches,
nausea, vomiting, and diarrhea or other nonspecific
symptoms. Most textbook descriptions of symptoms
relate to acute poisoning, usually among agriculture
workers. Although these symptoms can be seen in
persons exposed to contamination in the home, in cases
of chronic low-dose exposure, symptoms and signs
might be more subtle. Children (particularly less than
6 months of age), pregnant women and homebound
adults are considered particularly susceptible populations.
Testing
Traditionally, red cell cholinesterase has been the
preferred method of confirming cholinesterase-inhibiting
pesticide toxicity. However, because the range of nor-
mal red cell cholinesterase is so wide, depression of
cholinesterase levels is often difficult to confirm. More-
over, cholinesterase depression is not specific to me-
thyl parathion and may occur with other organophos-
phates, as well as in early pregnancy, distance run-
ners, liver disease and oral contraceptive use. If you
594
believe it is likely a that patient's illness may be re-
lated to methyl parathion exposure, red cell or plasma
cholinesterase may be useful, but serial measurement
over several months may be necessary to demonstrate
a change from baseline.
Treatment
The first step in treatment for individuals with
demonstrated high exposure (high levels in home) is
removal from the source. Treatment for clinically symp-
tomatic poisoning is covered in most standard texts
and usually includes atropine, pralidoxime (2-PAM)
and supportive therapy. After interruption of expo-
sure, clinical symptoms usually resolve rapidly.
Long-term human health effects related to exposure
to methyl parathion have not been demonstrated.
Resources
A case study titled " Cholinesterase-Inhibiting Pesti-
cide Toxicity" is available for those desiring further in-
formation. Continuing medical education credit (CME)
is available to physicians who complete the case study.
If you would like a copy of the case study please call
(501)661-2604.
For more information on symptoms, testing and
treatment of methyl parathion, please contact the Ar-
kansas Department of Health, Division of Epidemiol-
ogy at (501)661-2597 during normal business hours.
SEEKING PHYSICIAN
Multi-disciplined Practice in Fort
Smith, AR Seeking Physician for
Full or Part Time Position.
No Evenings or Weekends Required.
Please Call for Details
501-785-0400
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Reported Cases of Selected Diseases in Arkansas Profile for February 1997
The three-month delay in the disease profile for a given month is designed to minimize any changes that may occur due
to the effects of late reporting. The numbers in the table reflect the actual disease onset date, if known, rather than the date
the disease was reported.
Selected
Reportable
Diseases
Total
Reported
Cases
Feb. 1997
Total
Reported
Cases
YTD1997
Total
Reported
Cases
YTD 1996
Total
Reported
Cases
1996
Total
Reported
Cases
YTD 1995
Total
Reported
Cases
1995
Campylobacteriosis
9
24
22
241
15
153
Giardiasis
12
27
21
182
22
131
Shigellosis
4
23
10
176
24
176
Salmonellosis
8
21
35
455
22
338
Hepatitis A
17
48
114
503
36
663
Hepatitis B
6
10
20
88
11
83
HIB
0
0
0
0
0
6
Meningococcal Infections
10
12
8
35
11
39
Viral Meningitis
2
4
6
38
0
33
Lyme Disease
0
0
1
27
2
12
Rocky Mountain Spotted Fever
0
0
0
22
0
31
Tularemia
0
0
0
20
1
22
Measles
0
0
0
0
2
2
Mumps
0
0
0
1
1
6
Gonorrhea
381
794
834
5050
564
5437
Syphilis
61
116
143
706
157
1017
Legionellosis
0
0
0
1
2
8
Pertussis
0
3
1
15
6
59
Tuberculosis
20
20
16
225
26
271
For a listing of reportable diseases in Arkansas, call the Arkansas Department of Health, Division of Epidemiology, at (501) 661-2893.
Volume 93, Number 12 - May 1997
595
New Members
BLYTHEVILLE
White, John S., Obstetrics/Gynecology. Medical
Education, Loyola University Stritch School of Medi-
cine, Maywood, IL, 1972. Internship/Residency, Los
Angeles County Hospital, CA, 1973/1976. Board certified.
EL DORADO
Schonefeld, Michael D., Nephrology. Medical
Education, Louisiana State University School of Medi-
cine, New Orleans, 1990. Internship/Residency/Fellow-
ship, UAMS. Board certified.
Winfrey, Cheryl D., Physical Medicine & Reha-
bilitation. Medical Education, East Tennessee State
University James Quillen College of Medicine, Johnson
City, 1992. Internship, University of Tennessee, Mem-
phis, 1993. Residency, Carolina's Medical Center, 1996.
FORREST CITY
Healy, Richard Oliver, Family Practice. Medical
Education, University College Dublin, Ireland, 1970.
Internship, Illinois Central Hospital, Chicago, 1971.
Residencies, Dalhouse University and University of
Tennessee, 1977/1996. Board certified.
LITTLE ROCK
Antakli, Tamim, Thoracic. Medical Education,
Aleppo University, Syria, 1983. Internship, Methodist
Hospital, Brooklyn, NY, 1989. Residencies, Methodist
Hospital, Brooklyn, NY, and UAMS, 1993/1996. Board
certified.
Grissom, James R., Medical Oncology and He-
matology. Medical Education, UAMS, 1975. Internship,
UAMS, 1976. Residency, Tulane University Medicine
Program, New Orleans, 1979. Board certified.
Harms, Steven, E., Radiology. Medical Education,
UAMS, 1978. Internship, University Hospital, 1979.
Residency, UAMS, 1982. Board certified.
PARAGOULD
Sangster, William McCoy, General Surgery. Medi-
cal Education, University of Missouri School of Medi-
cine, Columbia, 1973. Internship/Residency, Univer-
sity of Missouri, 1974/1982. Board certified.
PINE BLUFF
Harvey, Jerry Lynn, Family Practice. Medical Edu-
cation, Oklahoma State University - College of Osteo-
pathic Medicine, 1993. Internship/Residency, AHEC-
Pine Bluff, 1994/1996. Board certified.
Tejada, Ruben, Internal Medicine. Medical Edu-
cation, Universidad Central del Este, Dominican Republic,
596
1988. Internship, Centro Medico U.E.E., Dominican
Republic, 1989. Residency, Raritan Bay Medical Cen-
ter, New Jersey, 1996.
WARREN
Purvis, Kenneth W, Family Practice. Medical Edu-
cation, University of Texas Medical Branch, Galveston,
1978. Internship/Residency, John Peter Smith Hospi-
tal, 1979/1981. Board certified.
WEST MEMPHIS
Ward-Jones, Susan Elizabeth, Internal Medicine.
Medical Education, UAMS, 1993. Internship/Residency,
UAMS, 1994/1996.
WHITE HALL
Coleman, Roy Douglas, Family Practice. Medical
Education, UAMS, 1993. Residency, AHEC-Pine Bluff,
1996. Board certified.
RESIDENTS
Chumley, Willard Truman Jr., Anesthesiology.
Medical Education, UAMS, 1993, Internship, AHEC-
Pine Bluff, 1994. Residency, UAMS.
Graves, Charles Leon, Psychiatry. Medical Edu-
cation, UAMS, 1993. Residency/Fellowship, UAMS.
Haley, Tonya, Pediatrics & Neurology. Medical
Education, UAMS, 1991. Internship, UAMS, 1992.
Residency, Children's Hospital Medical Center.
Hall, John Culley, Emergency Medicine. Medical
Education, University of Texas Southwestern Medical
School, Dallas, 1995. Residency UAMS.
Heise, Brian Allan, Family Medicine. Medical
Education, Louisiana State University Medical Cen-
ter, Shreveport, 1995. Internship/Residency, Univer-
sity of Texas Medical Branch, Galveston.
Hutcheson, James Arthur, General Surgery/Oto-
laryngology. Medical Education, UAMS, 1995. Intern-
ship/Residency, UAMS.
Kazakevicius, Rimantas, Surgery/Family Medicine.
Medical Education, Vilnius University Medical Faculty,
Lithuania, 1980. Internships, Vilnius University Clinic
and UAMS.
Rohde, Melinda S., Pediatrics. Medical Education,
University of Oklahoma College of Medicine, Okla-
homa City, 1995. Residency, UAMS.
STUDENTS
Michael Gregg Barden
Jacqueline Sherrill O'Donald
David Neal Shenker
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Ml
AMS Sponsors Workshops
in Little Rock
October 16. 1997
Managed Care Update:
Advanced Strategies for Practice Survival
This workshop will show you how to become more proactive in the managed care marketplace.
Numerous case examples will be used to illustrate the following topics:
* getting into the better plans *
* tracking managed care plan results *
* reorganize some of the staff jobs *
* learn about outcome studies *
* determine ways to reduce practice overhead in a reduced-reimbursement environment *
December 4. 1997
Coding Analysis to Maximize Reimbursement in 1997
A hands-on workshop with informative case studies. Major emphasis is on the complex rela-
tionship between the procedure, the diagnosis, place of service, provider status and patient
financial class for traditional and non-traditional (HMO/PPO) claims processing. Workshop
requires a background in the basics of CPT, ICD-9 and the HCFA-1 500.
For more information call 501-224-8967
Volume 93, Number 12 - May 1997
597
Western Wildlife
As Kasirnirrs movrri West, pioneers
found animuU as exotic as the land^j^^..
buffalo, prairie Jogs, bears. beaverf/Ugluir^ uvl
slirep, rougars. wolves and raitlesrfciMs.
The eagle became a national ssTnbol. <1 *. 1 * •
jt I he eagle becan^ a national ssTnbol. <1 j * • ** f
£yiULyj2Joa^ » tuyu^ 2!^
A^^UioCyioJ^^ri^ .
^40C!A.
thankyo^P^^'
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^^nd helpful
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^Pentior,
fowled,
'^ere wer
^oopleto.
ror more
information
on how
you can help,
call AHCAF at
(501)221-3033
r (800) 950-8233
Arkansas Health Care
Access FwindatiOT) Inc.
Hr those physicians who volunteer 1|
through the Arkansas Health |
r s^' Care Access Foundation, ^ \
if ■ Thank You!' .4'4?:.f
k:^ =:i': ,:> fcmsmms: s^sAiite
I As you can see from a sampling of
|v letters we have received, your -
mk involvement in our program is j
appreciated and in many
cases life-saving..^ ^■||
THANK YOU FOR MAKING THE DIFFERENCE!
Resolutions
Monroe Dixon McClain^ M.D.
WHEREAS, the members of the Pulaski County Medical Society are deeply saddened by the recent death of a
respected member, Monroe Dixon McClain, M.D.; and
WHEREAS, Dr. McClain was a loyal member of this organization since 1939, servicing capably and enthusiasti-
cally in numerous positions of leadership; and
WHEREAS, Dr. McClain's patriotism was evidenced by his distinguished service in the Medical Corps during
World War II; and
WHEREAS, his concern and compassion for his patients will be remembered as the hallmark of his practice;
BE IT THEREFORE RESOLVED:
THAT, this resolution be adopted and filed in the permanent records of this Society; and
THAT, a copy be sent to Dr. McClain's family as a token of our true sympathy; and
THAT, a copy be made available to The Journal of the Arkansas Medical Society for publication.
All Resolutions Adopted
Board of Directors
March 26, 1997
By Order of the Memorials Committee
Fred O. Henker, 111, M.D., Chairman
James W. Headstream, M.D.
Bruce E. Schratz, M.D.
Ferdinand E. Greifenstein, M.D.
WHEREAS, the members of the Pulaski County Medical Society note with sincere sorrow the recent death of an
esteemed colleague, Ferdinand E. Greifenstein, M.D.; and
WHEREAS, Dr. Greifenstein was a member of this society for many years always giving generously of his time
and talent towards its betterment; and
WHEREAS, Dr. Greifenstein will be long remembered by his peers, friends and family as a gracious and caring
man who dedicated his life to the service of others;
BE IT THEREFORE RESOLVED:
THAT, this resolution be adopted and placed in the archives of this Society; and
THAT, a copy be forwarded to Dr. Greifenstein's family as an expression of our sympathy; and
THAT, a copy be made available to The Journal of the Arkansas Medical Society for publication.
All Resolutions Adopted By Order of the Memorials Committee
Board of Directors Fred O. Henker, III, M.D., Chairman
March 19, 1997 James W. Headstream, M.D.
Bruce E. Schratz, M.D.
Volume 93, Number 12 - May 1997
599
Things To Come
June 6-8
Alumni Weekend '97 - University of Arkansas
College of Medicine Alumni. Alumni Classes of 1932,
1937, 1942, 1947, 1952, 1957, 1962, 1967, 1972, 1977,
1982 and 1987 will be reuniting this year for a variety
of special activities beginning on Friday afternoon, June
6th and ending with a brunch on Sunday, June 8th.
All alumni and Caduceus Club members are welcome
to attend. Call the Arkansas Caduceus Club at (501)
686-6684 for registration forms and more information.
June 10-11
19th Annual General Motors Cancer Research
Foundation Annual Scientific Conference. National
Institutes of Health, Bethesda, Maryland. For more
information, call (202) 636-8745.
June 26-27
The Effectiveness of Prenatal Care: New Evidence,
New Paradigms. Harvard School of Public Health,
Harvard Longwood Medical Campus, Boston, Massa-
chusetts. Presented by the Department of Maternal
and Child Health and the Harvard Center for Children's
Health. Supported by a grant from the Agency for
Health Care Policy and Research. For more informa-
tion, call (617) 432-1171.
July 4-6
27th Annual Sports Medicine Symposium.
Sheraton Atlantic Beach Resort, Atlantic Beach, North
Carolina. Presented by the Sports Medicine Commit-
tee of the North Carolina Medical Society. For more
information, call (800) 722-1350.
July 7-10
17th Annual Current Concepts in Primary Care
Cardiology. Hyatt Regency Lake Tahoe, Incline Vil-
lage, Nevada. Sponsored by UC Davis School of Medi-
cine and Medical Center, Division of Cardiovascular
Medicine and Office of Continuing Medical Education.
For more information, call (916) 734-5390.
July 12-18
22nd Annual National Wellness Conference. Uni-
versity of Wisconsin, Stevens Point, Wisconsin. For
more information, call (800) 243-8694.
September 4-6
International Symposium on Gasless
Laparoscopy. Bochum, Germany. Sponsored by the
American Association of Gynecologic Laparoscopists.
For more information, call 1-800-554-2245.
600
September 5-7
4th Annual Current Topics in Cardiothoracic An-
esthesia. Washington University Medical Center, St.
Louis, Missouri. Sponsored by the Office of Continu-
ing Medical Education, Washington University School
of Medicine. For more information, call 1-800-325-9862.
September 18-20
Contemporary Cardiothoracic Surgery. Washing-
ton University Medical Center, St. Louis, Missouri.
Sponsored by the Office of Continuing Medical Edu-
cation, Washington University School of Medicine. For
more information, call 1-800-325-9862.
September 23-28
International Congress of Gynecologic Endoscopy/
AAGL 26th Annual Meeting. The Washington State
Convention & Trade Center, Seattle, Washington.
Sponsored by the American Association of Gyneco-
logic Laparoscopists. For more information, call 1-800-
554-2245.
October 15-19
2nd Annual CME Course - Infectious Disease '97
Board Review: A Comprehensive Review for Board
Preparation. The Ritz-Carlton, Tysons Corner, McLean,
Virginia. Sponsored by The Center for Bio-Medical
Communication, Inc. For more information, call (201)
385-8080.
October 26-30
1997 State-of-the-Art Conference: Occupational
and Environmental Medicine. Nashville, Tennessee.
Sponsored by the American College of Occupational
and Environmental Medicine. For more information,
call (847) 228-6850, ext. 152.
November 13-14
23rd Annual Symposium on Obstetrics & Gyne-
cology. Washington University Medical Center, St.
Louis, Missouri. Sponsored by the Office of Continu-
ing Medical Education, Washington University School
of Medicine. For more information, call 1-800-325-9862.
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Keeping Up
May 30 - June 1
I9th Annual Family Practice Intensive Review. Location: CAMS,
Education II Building, Little Rock. Program Presenters: Department
of Family and Community Medicine. Accrediting organization spon-
soring program: UAMS College of Medicine. Hours of Category 1
credit offered: Up to 20 hours of CME credit. Fee: TBA. For more
information, call 501-661-7962.
October 3-5
Primary Care Update (Management of Top 20 Ambulatory Di-
agnoses). Location: Gaston's Lodge on the White River. Sponsor:
Washington Regional Medical Center. For more information, call
501-442-1823 or 1-800-422-0322.
Recurring Education Programs
The following organizations are accredited by the Arkansas Medical Society to sponsor continuing medical education for physicians. The
organizations named designate these continuing medical education activities for the credit hours specified in Category 1 of the Physician's
Recognition Award of the American Medical Association.
FAYETTEVILLE-VA MEDICAL CENTER
General Internal Medicine Review, Wednesdays, 12:00 noon. Room 238 Bldg. 1
Medical Grand Rounds/ General Medical Topics, Thursdays, 12:00 noon. Auditorium, Bldg. 3
FAYETTEVILLE-WASHINGTON REGIONAL MEDICAL CENTER
Cardiology Conference, 3rd Wednesday of every month, 7:30 - 8:30 a.m., WRMC, Baker Conference Center, no fee, breakfast provided
Chest Conference, 1st Wednesday of every month, 12:15 - 1:15 p.m., WRMC, Baker Conference Center, no fee, lunch provided
Primary Care Conferences, every Monday, 12:15 - 1:15 p.m., WRMC, Baker Conference Center, no fee, lunch provided
Tumor Conference, every Thursday, 7:30 - 8:30 a.m., WRMC, Baker Conference Center, no fee, breakfast provided
HARRISON-NORTH ARKANSAS MEDICAL CENTER
Cancer Conference, 4th Thursday, 12:00 noon. Conference Room
LITTLE ROCK-ST. VINCENT INFIRMARY MEDICAL CENTER
Arkansas Blood & Cancer Society Conference, 6th Thursday, 7:30 p.m.. Terrace Restaurant
Cancer Conferences, Thursdays, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
General Surgery Grand Rounds, 1st Thursday, 7:00 a.m. Southwestern Bell/Arkla Room. Light breakfast provided.
Interdisciplinary AIDS Conference, 2nd Friday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Journal Club, Tuesdays, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
Mental Health Conference, 3rd Wednesday, 12:00 noon. Southwestern Bell/Arkla room. Lunch provided.
Pulmonary Conference, 4th Wednesday, 12:00 noon. Southwestern Bell/Arkla Room. Lunch provided.
LITTLE ROCK-BAPTIST MEDICAL CENTER
Breast Conference, 3rd Thursday, 7:00 a.m., J.A. Gilbreath Conference Center, Room #20
Grand Rounds Conference, Wednesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Pulmonary Conference, Tuesdays, 12:00 noon, Shuffield Auditorium. Lunch provided.
Sleep Disorders Case Conference, Fridays, 12:00 noon. Call BMC ext. 1902 for location. Lunch provided.
MOUNTAIN HOME-BAXTER COUNTY REGIONAL HOSPITAL
Lecture Series, 3rd Tuesday, 6:30 p.m.. Education Building
Tumor Conference, Tuesdays, 12:00 noon, Carti Boardroom
The University of Arkansas College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor the
following continuing medical education activities for physicians. The Office of Continuing Medical Education designates that these activities
meet the criteria for credit hours in category 1 toward the AMA Physician's Recognition Award. Each physician should claim only those
hours of credit that he/she actually spent in the educational activity.
LITTLE ROCK-ARKANSAS CHILDREN'S HOSPITAL
Faculty Resident Seminar, 3rd Thursday, 12:00 noon, Sturgis Auditorium
Genetics Conference, Tuesdays, 1:00 p.m.. Conference Room, Springer Building
Infectious Disease Conference, 2nd Wednesday, 12:00 noon, 2nd Floor Classroom
Pediatric Grand Rounds, Tuesdays, 8:00 a.m., Sturgis Bldg., Auditorium
Pediatric Neuroscience Conference, 1st Thursday, 8:00 a.m., 2nd Floor Classroom
Pediatric Pharmacology Conference, 5th Wednesday, 12:00 noon, 2nd Classroom
Pediatric Research Conference, 1st Thursday, 12:00 noon, 2nd Floor Classroom
LITTLE ROCK-UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
ACRC Multi-Disciplinary Cancer Conference (Tumor Board), Wednesdays, 12:00 noon, ACRC 2nd floor Conference Room.
Volume 93, Number 12 - May 1997
601
Anesthesia Grand Rounds/M&M Conference, Tuesdays, 6:00 a.m., UAMS Education III Bldg., Room 0219.
Autopsy Pathology Conference, Wednesdays, 8:30 a.m., VAMC-LR Autopsy Room.
Cardiology-Cardiovascular & Thoracic Surgery Conference, Wednesdays, 11:45 a.m., UAMS, Shorey Bldg., room 3S/06
Cardiology Grand Rounds, 2nd & 4th Mondays, 4:00 p.m., UAMS Shorey Bldg., 3S/06
Cardiology Morning Report, every morning, 7:30 a.m., UAMS, Shorey Bldg, room 3S/07
Cardiothoracic Surgery M&M Conference, 2nd Saturday each month, 8:00 a.m., UAMS, Shorey Bldg, room 2S/08
CARTI/Searcy Tumor Board Conference, 2nd Wednesday, 12:30 p.m., CARTI Searcy, 405 Rodgers Drive, Searcy.
Centers for Mental Healthcare Research Conference, 1st & 3rd Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr.
CORE Research Conference, 2nd & 4th Wednesday each month, 4:00 p.m., UAMS, Child Study Ctr., 1st floor auditorium
Endocrinology Grand Rounds, starting October 1996, Fridays, 12:00 noon, ACRC Bldg., Sam Walton Auditorium, 10th floor
Gastroenterology Grand Rounds, Thursdays, 4:00 p.m., UAMS Hospital, room 3D29 (1st Thurs. at ACH)
Gastroenterology Pathology Conference, 4:00 p.m., 1st Tuesday each month, UAMS Hospital
GI/Radiology Conference, Tuesdays, 8:00 a.m., UAMS Hospital, room 3D29
In-Vitro Fertilization Case Conference, 2nd & 4th Wednesdays each month, 11:00 a.m.. Freeway Medical Tower, Suite 502 Conf. rm
Medical/ Surgical Chest Conference, each Monday, 4:00 p.m., UAMS Hospital, room Ml/293
Medicine Grand Rounds, Thursdays, 12:00 noon, UAMS Education II Bldg., room 0131
Medicine Research Conference, one Wednesday each month, 4:30 p.m. UAMS Education II Bldg, room 0131A
Neuropathology Conference, 2nd Wednesday each month, 4:00 p.m., AR State Crime Lab, Medical Examiner's Office
Neurosurgery, Neuroradiology & Neuropathology Case Presentations, Thursdays, 4:00 p.m., UAMS HospitalOB/GYN Fetal
Boards, 2nd Fridays, 8:00 a.m., ACH Sturgis Bldg.
OB/GYN Grand Rounds, Wednesdays, 7:45 a.m., UAMS Education II Bldg., room 0141A
Ophthalmology Problem Case Conference, Thursdays, 4:00 p.m., UAMS Jones Eye Institute, 2 credit hours
Orthopaedic Basic Science Conference, Tuesdays, 7:30 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Bibliography Conference, Tuesdays, Jan. - Oct., 7:30 a.m., UAMS Education II Bldg.
Orthopaedic Fracture Conference, Tuesdays, 9:00 a.m., UAMS Education II Bldg., room B/107
Orthopaedic Grand Rounds, Tuesdays, 10:00 a.m., UAMS Education II Bldg., room B/107
Otolaryngology Grand Rounds, 2nd Saturday each month, 9:00 a.m., UAMS Biomedical Research Bldg., room 205
Otolaryngology M&M Conference, each Monday, 5:30 p.m., UAMS Otolaryngology Conf. room
Perinatal Care Grand Rounds, every Tuesday, 12:15 p.m., BMC, 2nd floor Conf. room
Psychiatry Grand Rounds, Fridays, 11:00 a.m., UAMS Child Study Center Auditorium
Surgery Grand Rounds, Tuesdays, 8:00 a.m., ACRC Betsy Blass Conf.
Surgery Morbidity & Mortality Conference, Tuesdays, 7:00 a.m., ACRC Betsy Blass conference room, 2nd floor
NLRVA Geriatric/Medicine Grand Rounds, Thursdays, 8:00 a.m., VAMC-NLR, Bldg 68, room 130
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E-142
VA Medical Service Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D109
VA Medicine Pathology Conference, Tuesdays, 2:00 p.m., VAMC-LR, room 2D109
VA Pathology-Hematology/Oncology-Radiology Patient Problem Conference, Thursdays, 8:15 a.m., VAMC-LR, room 2E142
VA Physical Medicine & Rehab Grand Rounds, 4th Friday each month, 11:30 a.m., VAMC-NLR, Bldg. 68
VA Topics in Physical Medicine & Rehab Seminar, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68
VA Psychiatry Difficult Case Conference, 4th Monday, 12:00 noon, VAMC-NLR, Mental Health Clinic
VA Surgery M&M Conference (Grand Rounds), Thursdays, 12:45 p.m., VAMC-LR, room 2D109
VA Lung Cancer Conference, Thursdays, 3:00 p.m., VAMC-LR, room 2E142
VA Medical Service Teaching Conference, Thursdays, 8:00 a.m., VAMC-NLR, Bldg. 68 room 130
VA Medicine-Pathology Conference, Tuesday, 2:00 p.m., VAMC-LR, room 2D109
VA Medicine Resident's Clinical Case Conference, Fridays, 12:00 noon, VAMC-LR, room 2D08
VA Physical Medicine & Rehab Grand Rounds, 4th Friday, 11:30 a.m., VAMC-NLR Bldg. 68, room 118 or Baptist Rehab Institute
VA Surgery Grand Rounds, Thursdays, 12:45 p.m., VAMC-LR, room 2D109, 1.25 credit hours
VA Topics in Rehabilitation Medicine Conference, 2nd, 3rd, & 4th Thursdays, 8:00 a.m., VAMC-NLR Bldg. 68, room 118
VA Weekly Cancer Conference, Monday, 3:00 p.m., VAMC-LR, room 2E-142
White County Memorial Hospital Medical Staff Program, once monthly, dates & times vary. White County Memorial Hospital, Searcy
EL DORADO-AHEC
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., Warner Brown Campus, 6th floor Conf. Rm.
Behavioral Sciences Conference, 1st & 4th Friday, 12:15 p.m., AHEC - South Arkansas
Chest Conference, 3rd Wednesday, 12:15 p.m.. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Dermatology Conference, 1st Tuesdays and 1st Thursdays, AHEC - South Arkansas
GYN Conference, 2nd Friday, 12:15 p.m., AHEC-South Arkansas
Internal Medicine Conference, 1st, 2nd & 4th Wednesday, 12:15 p.m., AHEC-South Arkansas
Noon Lecture Series, 2nd & 4th Thursday, 12:00 noon. Union Medical Campus, Conf. Rm. #3. Lunch provided.
Pathology Conference, 2nd Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5. Lunch provided.
Pediatric Conference, 3rd Friday, 12:15 p.m., AHEC - South Arkansas
Pediatric Case Presentation, 3rd Tuesday, 3rd Friday, AHEC - South Arkansas
Arkansas Children's Hospital Pediatric Grand Rounds, every Tuesday, 8:00 a.m., AHEC - South Arkansas (Interactive video)
Pathology Conference, 2nd Tuesday, 12:15 p.m., AHEC - South Arkansas
602
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Dbstetrics-Gynecology Conference, 4th Thursday, 12:15 p.m., AHEC - South Arkansas
Surgical Conference, 1st, 2nd & 3rd Monday, 12:15 p.m., AHEC - South Arkansas
Tumor Clinic, 4th Tuesday, 12:15 p.m., Warner Brown Campus, Conf. Rm. #5, Lunch provided.
VA Hematology /Oncology Conference, Thursdays, 8:15 a.m., VAMC-LR Pathology conference room 2E142
FAYETTEVILLE-AHEC NORTHWEST
AHEC Teaching Conferences, Tuesdays & Wednesdays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Fridays, 12:00 noon, AHEC Classroom
AHEC Teaching Conferences, Thursdays, 7:30 a.m., AHEC Classroom
Medical/ Surgical Conference Series, 4th Tuesday, 12:30, Bates Medical Center, Bentonville
FORT SMITH-AHEC
Crand Rounds, 12:00 noon, first Wednesday of each month. Sparks Regional Medical Center
Neuroscience & Spine Conference, 3rd Wednesday each month, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Mondays, 12:00 noon, St. Edward Mercy Medical Center
Tumor Conference, Wednesdays, 12:00 noon. Sparks Regional Medical Center
JONESBORO-AHEC NORTHEAST
AHEC Lecture Series, 1st & 3rd Tuesday, 12:00 noon, Stroud Hall, St. Bernard's Regional Medical Center. Lunch provided.
Arkansas Methodist Hospital CME Conference, 7:30 a.m.. Hospital Cafeteria, Arkansas Methodist Hospital, Paragould
Chest Conference, 2nd Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Citywide Cardiology Conference, 3rd Thursday, 7:30 p.m., Jonesboro Holiday Inn
Clinical Faculty Conference, 5th Tuesday, St. Bernard's Regional Medical Center, Dietary Conference Room, lunch provided
Craighead/ Poinsett Medical Society, 1st Tuesday, 7:00 p.m. Jonesboro Country Club
Creenleaf Hospital CME Conference, monthly, 12:00 noon, Greenleaf Hospital Conference Room. Lunch provided.
Independence County Medical Society, 2nd Tuesday, 6:30 p.m., Batesville Country Club, Batesville
Interesting Case Conference, 4th Tuesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Jackson County Medical Society, 3rd Thursday, 7:00 p.m., Newport Country Club, Newport
Kennett CME Conference, 3rd Monday, 12:00 noon. Twin Rivers Hospital Cafeteria, Kennett, MO
Methodist Hospital of Jonesboro Cardiology Conference, every other month, 7:00 p.m., alternating between Methodist Hospital
Conference Room and St. Bernard's, Stroud Hall. Meal provided.
Methodist Hospital of Jonesboro CME Conference, 2nd Tuesday, 7:00 p.m.. Cafeteria, Methodist Hospital of Jonesboro
Neuroscience Conference, 3rd Monday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch Provided.
Orthopedic Case Conferences, every other month beginning in January, 7:30 a.m.. Northeast Arkansas Rehabilitation Hospital
Perinatal Conference, 2nd Wednesday, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Piggott CME Conference, 3rd Thursday, 6:00 p.m., Piggott Hospital. Meal provided.
Pocahontas CME Conference, 3rd Wednesday, 12:00 noon & 7:30 p.m., Randolph County Medical Center Boardroom
Tumor Conference, Thursdays, 12:00 noon, St. Bernard's Dietary Conference Room. Lunch provided.
Walnut Ridge CME Conference, 3rd & last Tuesday, 12:00 noon, Lawrence Memorial Hospital Cafeteria
White River CME Conference, 3rd Thursday, 12:00 noon. White River Medical Center Hospital Boardroom
PINE BLUFF-AHEC
Behavioral Science Conference, 1st & 3rd Thursday, 12:00 noon, Jefferson Regional Medical Center
Cardiology Conference, dates vary, 7:00 p.m., locations vary
Chest Conference, 2nd & 4th Friday, 12:00 noon, Jefferson Regional Medical Center
Family Practice Conference, 1st & 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
Geriatrics Conference, 4th Tuesday, 12:00 noon, Jefferson Regional Medical Center
nternal Medicine Conference, 2nd & 4th Thursdays, 12:00 noon, Jefferson Regional Medical Center
Obstetrics/Gynecology Conference, 2nd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Orthopedic Case Conference, 2nd & 4th Wednesdays, 12:00 noon, Jefferson Regional Medical Center.
Pediatric Conference, 3rd Wednesday, 12:00 noon, Jefferson Regional Medical Center
Radiology Conference, 3rd Tuesday, 12:00 noon, Jefferson Regional Medical Center
Southeast Arkansas Medical Lecture Series, 4th Tuesday, 6:30 p.m.. Pine Bluff County Club. Dinner meeting.
Tumor Conference, 4th Tuesday, 12:00 noon. Medical Center of South AR, Warner Brown Campus
Tumor Conference, 1st Wednesday, 12:00 noon, Jefferson Regional Medical Center
TEXARKANA-AHEC SOUTHWEST
Chest Conference, every other 3rd Tuesday/quarterly, 12:00 noon, St. Michael Health Care Center
Neuro-Radiology Conference, 1st Thursday every month at St. Michael Health Care Center and 3rd Thursday of ever month
at Wadley Regional Medical Center, 12:00 noon.
Residency Noon Conference, Monday, Wednesday, Thursday, Friday each week, alternates between St. Michael Health Care
Center & Wadley REgional Medical Center
Tumor Board, Fridays, except 5th Friday, 12:00 noon, Wadley Regional Medical Center & St. Michael Hospital
Tumor Conference, every 5th Friday, 12:00 noon alternates between Wadley Regional Medical Center & St. Michael Hospital
Volume 93, Number 12 - May 1997
603
The Journal of the Arkansas Medical Society
Index 1996-1997
Volume 93, Numbers 1-12
(O) Original Article; (SP) Special Article; (OB) Obituary; (R) Resolution; (E) Editorial
-A-
AMS Newsmakers 11, 75, 122, 171, 227, 277, 322,
386, 438, 478, 516, 580
Abbott, William Wood (OB) 153
Abbott, William Wood (R) 259
Abel, Lee (E) 68, 316
Albey, Mark (SP) 181
Alderson, Sheila Horan (O) 333
Allen, Ruth (SP) 175
Allergies and Allergic Rhinitis, Nothing to Sneeze
About (SP) 81
Anaphylaxis; Multiple Etiologies - Focused Therapy (O) 281
Anderson, N. Karol (O) 203
Arkansas HIV/AIDS Report 52, 96, 146, 198, 246,
414, 560
Arkansas Medical Society:
1996 MED PAC Contributors 552
1996 Membership Roster 355
1997 AMS "Doctor of the Day" Calendar 397
1997 MED-PAC Contributors 551
12P' AMS Annual Session Schedule & Speakers 517
AMS Alliance Annual Session Report &
Presidential Address 33
AMS Alliance News 255
AMS Annual Session Registration Form 522
AMS Business Reports for Reference Committee #1 529
AMS Business Reports for Reference Committee #2 529
AMS Convention Highlights and Alliance
Schedule 520
AMS House of Delegates 524
AMS Immediate Past President James
Armstrong, M.D., In Fond Memory of (SP) 155
AMS Nominating Committee Report 527
AMS Reference Committee Agendas 528
AMS Shuffield Award 37
Annual Session Exhibitors 42
Annual Session Sponsors 40
Convention Keynote Speakers 18
Fifty Year Club 36, 523
Grand Prize Winners 39
Farewell Address 30
House of Delegates Composition 20
Inaugural Address (SP) 15
Memorials 554
Minutes of the AMS House of Delegates
Fall 1996 Meeting 396
Proceedings of the 120"’ Annual Session 22
Arkansas Physicians in the AMA- Your Representatives
to Medicine's Strongest Voice (SP) 404
Armstrong, James D. (OB) 153
604
Armstrong, James, In Fond Memory of AMS Imme-
diate Past President (SP) 155
Ascending and Aortic Arch Aneurysm/Dissection,
Progress Report: Evaluation and Treatment of (O) 481
Assessing Clinical Skills of Medical Students (SP) 175
Avery, J. Kelley (SP) 235, 289, 339, 407, 452, 485, 587
Avva, Ramesh (O) 303
-B-
Backflow Prevention Devices Required for Medical
Facilities on many Public Water Systems (SP) 125
Balancing on a Four-legged Stool (E) 432
Beadle, Beverly A. (O) 257
Benafield, Robert B. (OB) 461
Bennett, Col. Eaton Wesley (OB) 461, (R) 502
Bevans, David W (O) 565
Bissett, Joe (O) 410
Boyles, Mindy D. (O) 47
Bryles, Robert S. (OB) 153
Breastfeeding in Arkansas: The Role of the Arkansas
Department of Health (SP) 185
Breastfeeding in Arkansas: Trends in the Northeast
Region and Physician Self Assessment Quiz (SP) 181
Building of the Land of Opportunity, The (E) 164
Bunch, Jan (SP) 245
Button Gastrostomy Tube, Long term Complication
of (O) 269
Byrum, Jerry (E) 380
-c-
Calandro, Vito (O) 291, (O) 490
Cantrell, Mary (SP) 175
Cardiology Commentary & Update:
Ilb/IIIa Platelet Inhibitors in the Management of
Coronary Artery Disease (O) 237
Advances in the Treatment of Left Ventricular
Systolic Dysfunction (O) 291
Adverse Drug Reactions (O) 340
ECG and Cardiac Enzymes Changes Associated
with Subarachnoid Hemorrhage (O) 592
Gloves: Friend or Foe? (O) 47
Lidocaine-Induced Cardiac Asystole (O) 410
Low-Molecular Weight Heparins (O) 555
Primary Prevention of Coronary Artery Disease
(O) 89
Secondary Prevention of Coronary Artery
Disease (O) 139
Stress Electrocardiography: A Review (O) 490
Syncope and Aortic Valve Stenosis: Clues to
Diagnosis and Pathophysiology (O) 191
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Vascular Health: The Emerging Appreciation of
the Endothelium (O) 454
Carfagno, Jeffrey J. (O) 257
Cason, Gerald J. (SP) 175
Challenges and rewards of being a rural physician.
The, Through barbed wire and over a fence, to
grandmother's house we go (E) 472
Changes in Galactosemia Screening Program (O) 327
Chapman, Jerry C., Sr. (OB) 502
Christy, George W. (O) 499
Clinical Skills of Medical Students, Assessing (SP) 175
Clinicopathological Images:
Pseudomembranous Colitis (O) 489
Collier, George H., Jr. (OB) 153
Crow, Neil E., Sr., (OB) 421
-D-
Dietz, Tracy (O) 139, (O) 490
Dinh, Ha (O) 490
Dramatic Changes are Taking Place in the Twin
Cities (SP) 131
-E-
Eans, Thomas L. (SP) 125
Eidt, John F. (O) 303
Ellerbee, Susan M. (SP) 185
Elovitz, Maurice J. (OB) 259
Emergency Medicine:
Delayed Cardiac Tamponade following a Stab
Wound: A Case Report (O) 589
-F-
Family Practice Residency Program Comes of Age,
The State's Newest (SP) 133
Farris, Guy R. (OB) 348
Finkbeiner, Alex E. (E) 116, 432
Finley, George M. (SP) 133, 449
Fitzgerald, Charles P. (O) 349
-G-
Galactosemia Screening Program, Changes in (O) 327
Gardner, Stephanie F (O) 340
Garrison, Stephen F (O) 137
Gastrointestinal Endoscopy Privileges in Arkansas -
A Hospital Survey (SP) 231
Getting Acquainted:
Samuel E. Landrum, M.D., Journal Editorial
Board Member (SP) 497
Ben N. Saltzman, M.D., Journal Editorial Board
Member (SP) 417
Gerald A. Stolz, Jr., M.D., Newly Elected
Chairman of the AMS Council (SP) 297
Golden, William E. (O) 329
Goldsmith, Geoffrey (SP) 231
Greifenstein, Ferdinand E. (R) 599
Guenthner, John F. (OB) 105
-H-
Haemophilus Influenzae Disease in Children, Invasive
Non-typeable (O) 137
Hardeman, Tyler (SP) 131
Harshfield, David L. (O) 101, 203, 303, 419, 499
Hayes, John M. (O) 565
Heard, Jeanne K. (SP) 175
Hellstern, Paul A. (O) 269
HIV/AIDS Surveillance Program - Conducting
Follow-up Investigations of Cases with No
Identified Risk (SP) 245
Hill, Allen Carruth (R) 502
Hoffman, Thomas H. (O) 459
Holloway, James D. (O) 459
How Much? (E) 220
Hyatt, Rebecca (SP) 133, 449
-I-
In Memoriam 105, 153, 211, 259, 307, 348, 421, 461,
502, 567
Ingram, Jim Mark (SP) 81
Invasive Non-typeable Haemophilus Influenzae Disease
in Children (O) 137
Investment Advice - Who Do You Call? (O) 585
Ivers, David L. (O) 79, 129
-J-
James, John M. (O) 281
Javier, Julian (O) 291
-K-
Keeping Up 59, 107, 157, 213, 260, 309, 352, 424, 464,
504, 569, 601
Kennedy, Eleanor E. (O) 151
Kennedy, Elicia Sinor (c3) 589
Kolb, James M, Jr. (SP) 404
Kolb, W. Payton, M.D., Tribute to a Political Leader
(SP) 395 (OB) 421 (R) 502
-L-
Landrum, Samuel E. (E) 220 (SP) 497
Legally Speaking:
Basic Rules for Being a Witness (O) 129
Basic Rules of Being an Expert Witness (O) 79
Legislative Issues Listed (SP) 392
Legislative Outlook (SP) 391
Legislator Information List (SP) 394
Let's Build a Medical Care Delivery System Like We
Built the Atomic Bomb (E) 116
Li, James T.C. (SP) 582
Long term Complication of Button Gastrostomy
Tube (O) 269
Loss Prevention Case Study:
A Good History Usually Gives A Diagnosis (SP) 587
Aggressive Mismanagement (SP) 339
Defensible Case Made Indefensible (SP) 452
Hazards of Heparin (SP) 407
Needed-Documentation in Quotation Marks (SP) 485
Post Cesarean Section Death (SP) 235
There Ain't No Justice (SP) 289
Volume 93, Number 12 - May 1997
605
-M-
Mail 118
Manavalan, Pius (O) 592
Mawulawde, Kwabena (O) 291
McClain, Monroe Dixon (R) 599
McFarland, David R. (O) 101, 303
McGehee, Mary A. (O) 445
McKee, Jack (O) 291
Meadors, Frederick A. (O) 481
Medical Students, Assessing Clinical Skills of (SP) 175
Medicine in the News 5, 71, 120, 167, 222, 272, 319,
383, 434, 474, 512, 576
Miller, Michael M. (O) 419
Morris, Harold Joseph (OB) 567
Moursi, Mohammed M. (O) 101
Moutos, Dean M. (O) 419
Murphy, Joseph S. (O) 55
Muscular Dystrophies, A Pulmonary Monitoring and
Treatment Plan for Children with Duchenne-
type (O) 333
-N-
Netchvolodoff, C.V. (O) 269
New Member Profile:
Allard, Mark Michael 279
Blackburn, Roy M. 325
Gray, George T., Ill 581
Miller, George Givens 123
Paul, William L. 173
Ruddell, Deanna Nicholson 443
Wait, Erik Jon 77
Yee, Suzanne W. 229
Malek S. Karassi 389
Molnar, Istvan 479
New Members 54, 99, 149, 200, 251, 299, 346, 418,
458, 596
News and Weather Report, The: Bad Moon Rising
and 111 Winds Blowing (E) 68
Nokes, Steven R. (O) 55, 151, 257, 349, 459, 565
Nothing to Sneeze About: Allergies and Allergic
Rhinitis (SP) 81
-o-
Outdoor MD (SP) 248, 298
-P-
Parker, Joe C. (OB) 211
Paslidis, Nick (O) 489
Patel, Naresh (O) 410
Patient-Physician Relationship, The: Covenant or
Contract? (SP) 582
Patient's Right to Know, The, - Full Disclosure Lazos
are Necessary for Patients and Physiciazis (SP) 402
Physician Practice Evaluations - Do the Exams Never
Stop? (E) 380
Physician Training for Specialist to Generalist Career
Change (SP) 449
Pierce, W Bradley (O) 151, 257
Pitts, Beth (O) 329
Political Leader, Tribute to a - W Payton Kolb, M.D.
(SP) 395
Progress Report: Evaluation and Treatment of
Ascending and Aortic Arch Aneurysm/Dissection
(O) 481
Pseudomembranous Colitis (O) 329
Pulmonary Monitoring and Treatment Plan for
Children with Duchenne-type Muscular E)ystrophies,
A (O) 333
-Q-
Qureshi, W.A. (O) 269
-R-
Radiological Case of the Month:
Arrhythmogenic right ventricular dysplasia (O) 151
Benign Simple Cyst, Benign Eibroadenoma &
Malignant Carcinoma of the Breast (O) 203
Bilateral Iliac Artery Atheroscerosis treated with
Balloon Angioplasty and Stent Placement
(O) 499
Calcified Uterine Leimyomata (O) 419
Ectopic Parathyroid Adenoma of the Upper
Mediastinum (O) 565
Hypothenar Hammer Syndrome (O) 303
Motion Artifact Simulating Aortic Dissection (O) 459
Peroneal Nerve Ganglion Cyst (O) 257
Renal Artery Stenosis Secondary to Atherosclerotic
Disease (O) 101
Right Coronary Artery Bypass Graft Aneurysm (O) 349
Sternalis Muscle (O) 55
Raney, Jerel Lee (O) 589
Rayford, Richard (O) 592
Residency Program Comes of Age, The State's
Newest Family Practice (SP) 133
Resolutions 259, 502, 599
Richardson, Derrick (O) 592
Rickard, Sherry (SP) 181
Roberts, Jon A. (O) 101
Roberts, William Joseph (OB) 307
Rural physician. The challenges and rewards of
being a, - Through barbed wire and over a fence,
to grandmother's house we go (E) 472
-s-
St. Pierre, Mark (O) 89
Sadikot, Ruxana (O) 410
Saltzman, Ben N. (E) 164 (SP) 417 (E) 472
Sanchez, Nena (O) 329
Schutze, Gordon E. (O) 137
Skaug, Warren (SP) 181
Smith, Eugene (O) 291
Smith, Richard, (O) 410
Socioeconomic Status, Race and Life Expectancy in
Arkansas, 1970-1990 (O) 445
State Health Watch 49, 93, 143, 195, 240, 295, 344,
412, 456, 495, 558, 594
State's Newest Family Practice Residency Program
606
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Comes of Age, The (SP) 133
Stolz, Gerald A. Jr., M.D., Getting Acquainted with.
Newly Elected Chairman of the AMS Council
Strange, Vance M. (OB) 211
Sure Proof, The (E) 316
Swanson, David A. (O) 445
-T-
Talley, J. David (O) 47, 89, 139, 191, 237, 291, 340,
410, 454, 490, 555, 592
Tank, Patrick W. (SP) 175
Things to Come 57, 105, 156, 212, 260, 308, 351, 423,
462, 503, 567, 600
Thomas, Don (O) 101
Thrasher, James R. (O) 191
Through barbed wire and over a fence, to
grandmother's house we go - The challenges
and rewards of being a rural physician (E) 472
Torres, Carlos (O) 489
Training for Specialist to Generalist Career Change,
Physician (SP) 449
Tribute to a Political Leader - W. Payton Kolb, M.D.
(SP) 395
Troupe, John (SP) 402
-w-
Walker, Ronald C. (O) 565
Warford, Walton R. (OB) 211
Warford, Walton R. (R) 259
Warren, Robert Hughes (O) 333
Waschka, Larry (O) 585
Webb, Malinda O. (SP) 185
West, Robert (O) 327
Wheeler, Richard P. (SP) 175
White, Laura M. (O) 340
Williams, C.D. (O) 349
-Y-
Yocum, John H. (O) 257
-z-
Zeno, Z. Lynn (SP) 391
Arkansas Medical Society
Index of New Members 1996-1997
Volume 93, Numbers 1-12
-A-
Abu-Hamda, Emad Mohammad (Resident) 300
Adams, Lennox Roosevelt (Resident) 201
Agee, Kimberly R. 251
Albin, Amy Wilson (Resident) 99
Alderink, Carlisle Julianna (Resident) 300
Allard, Mark Michael 201
Allen, Bernagie Eual 200
Alley, Jerri Lynn (Resident) 150
Andrews, Nancy Rai 54
Angtuaco, Sylvia Santos-Ocampo 200
Antakli, Tamim 596
Arrington, James Curely 346
Arthur, Lee Eric (Student) 300
Asi, Wael 99
-B-
Baber, Kimberly D. (Student) 347
Baho, Najla J. (Resident) 54
Bailey, Christopher Arnold 252
Bailey, Colin Raines 418
Bailey, Thomas O. (Resident) 201
Baker, Karen F. (Resident) 99
Baker, Mark Bradley (Student) 150
Ball, Charles S. 149
Banks, Holli Nicole (Student) 300
Barden, Michael Gregg (Student) 596
Bauer, David Harris 149
Bean, Paul Edward (Resident) 54
Bearden, Jeffrey Charles 251
Beau, Scott Lawrence 99
Beck, James Foster 149
Beckel, Ron W. 150
Beebe, William Edward 201
Beeman, David Lyn (Resident) 99
Behrens, Bing Xie (Resident) 300
Bell, Tanya R. (Student) 300
Bennett, Leigh Anne (Student) 458
Benson, Eric H. 149
Bhutta, Adnan T. (Resident) 300
Blackburn, Roy M. 99
Blackstock, Terri T. 299
Blackwood, Jann Belle (Resident) 201
Blake, Dennis Neal (Student) 100
Blankers, Christian Gerrit (Student) 300
Brandt, John Oliver 299
Bridges, James Scott (Student) 300
Brown, Richard Earl, Jr. 346
Brown, Robert D. (Resident) 54
Brownfield, Shannon Howard (Student) 202
Bruce, Thomas Allen 346
Volume 93, Number 12 - May 1997
607
Bryant, Bradley David (Student) 202
Bryant, Christopher Scott (Student) 252
Bryant, Gwendolyn Michelle (Student) 202
Burke, Charles Thomas (Resident) 54
Burton, Todd Michael (Resident) 99
Bush, John M. 418
-c-
Cain, Stephen Richard (Resident) 201
Calhoun, Aris Jeannette (Resident) 54
Calicott, Timothy 149
Cameron, Ricky Leon (Resident) 99
Campbell, Rachel Clare (Student) 202
Cannon, Robert David 150
Carey, Martin J. 346
Carr, Russell Shane (Resident) 100
Cash, James Steven 201
Cash, Paige Partridge (Resident) 150
Cate, Brian McDonald (Student) 252
Ceola, Ashley F. (Resident) 100
Chan, Kenneth 149
Chavis, Brent Daniel (Student) 252
Chodimella, Ushasree (Resident) 458
Christy, George William 54
Chumley, Willard Truman Jr. (Resident) 596
Clark, Teresa M. (Resident) 54
Clary, Cathy J. 54
Clements, Todd Michael (Student) 202
Chi, Jasen C. (Student) 150
Coffman, John Lawrence 346
Colclasure, Joe Christopher (Student) 300
Coleman, Roy Douglas 596
Collins, Gary J. 418
Collins, Kevin Basil 149
Contrucci, Ann L. 200
Cook, Jonathan Mitchell 346
Cook, Timothy Richard 99
Coombe Moore, Jackie M. 251
Cooper, Scott S. 150
Corbell, Mark Edward (Resident) 100
Covert, George Krueger 200
Covington, Brenda Kaye 299
Craytor, Bret Fredrick 300
Crews, Tracy Leigh (Student) 150
Crisp, Constance J. (Student) 300
Crow, Ronald Melton 251
Crownover, David Wayne (Student) 252
Cruz, Eduardo Vargas 99
Cruz, Lisa Renee Desbien (Resident) 201
Cullen, Robert Daniel (Student) 202
Cunningham, Darrin D. 251
Curtis, Brian (Student) 458
-D-
Dang, Minh-Tri Danny (Student) 202
Daniel, Jamie Dyan (Student) 150
Daniels, Charles Dwayne 299
Danner, Christopher James (Resident) 150
Darby, Scott Jason (Resident) 201
Daut, Peter Marshall (Student) 301
Davis, Richard Keith Jr. (Student) 202
Davis, Thomas Jay 299
Dennington, Elvin Lephiew (Student) 202
Deuter, Brian E. (Student) 252
Dickson, Brian Glenn (Resident) 54
Dickson, Scott Michael (Student) 301
Dolak, James Alexander 418
Douglas, Mary Frances (Student) 202
Doshi, Sangeeta H. 200
Duffield, Robin Pilgram (Resident) 100
Dugger, Joseph Scott (Resident) 54
Duke, Johnna Louise (Student) 202
Dunigan, Rodger Dale 299
-E-
Eads, Lou Ann (Resident) 100
Earl, Kevin Sam (Student) 202
Ebert, Robert H. (Student) 301
Edwards, Clinton Brough (Student) 202
El-Hayeck, Maroun Elie 346
Elliot, Jana Crain (Resident) 54
Engelkes, LaDonna Dichelle (Student) 301
Erwin, Steven Michael (Resident) 201
Esquibel, Ramona Dee (Resident) 300
-F-
Fahr, Michael J. (Resident) 100
Fant, Jerri S. (Resident) 201
Farrar, Jason Eli (Student) 150
Feild, Charles Robert 299
Ferguson, Philip Ellis (Student) 202
Fink, Roger Lee, II 251
Finkbeiner, Andrew Alex (Student) 252
Fitzgerald, Amy J. 54
Flamik, Darren E. 299
Flanigin, Richard C. 149
Fletcher, James William, III (Resident) 347
Fogata, Maria Luisa C. (Resident) 300
Fong, Shirley (Student) 202
Ford, Barry Graves 346
Foreman, Riley D. 200
Forte, Judith Lynn 251
Fox, Patrick J. (Student) 202
France, Vianne R. (Student) 202
Frankowski, Gary A. (Resident) 100
Fuller, Jon David (Student) 202
-G-
Gardial, Paul Richard (Student) 150
Garibaldi, Byron Thomas 200
Garrett-Shaver, Martha Gene (Student) 252
Gaston, Caleb Oakes (Student) 202
Ghan, Sheryl Evone 149
Glover, Forrest Daniel (Student) 202
Gluenck, Dane Andrew (Student) 202
Goosby, Nova Darcel (Student) 301
Gordon, Anthony K. (Resident) 201
Gordon, Eric Houston (Student) 202
Gordon, Gayle S. (Resident) 201
Gordon, Leonard F. 201
Graves, Charles Leon (Resident) 596
Gray, George T, III 251
608
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Greenwood, Denise Rochelle 251
Gregory, James Minor (Resident) 100
Gregory, Jo Anne 54
Gregory, John Reeves 99
Griffin, David Dean (Resident) 300
Grissom, James R. 596
Guerrero, David Andrew (Resident) 252
Gutierrez, Miguel Angel (Resident) 150
-H-
Haley, Tonya (Resident) 596
Hall, Avis Alphonso (Student) 301
Hall, John Gulley (Resident) 596
Hanby, Charles Kristian (Student) 252
Handley, David Lynn 200
Handloser, Holly Holland (Resident) 201
Hannon, Martin Alan (Student) 150
Haraway, Stuart D. 458
Hardin, Christopher Scott (Resident) 150
Hardin, Ronald David Jr. (Student) 150
Hardy, Ross Alan 458
Harik, Nada (Student) 301
Harms, Steven E. 596
Harris, Daniel J. (Student) 347
Harris, David Jay 251
Harris, Dehra Anne (Student) 202
Hart, Susan K. (Resident) 54
Hartman, Arthur Richard (Resident) 201
Hartman, Ray 149, 458
Harton, Timothy Scott (Student) 150
Harvey, Jerry Lynn 596
Hashmi, Shakeb 200
Hatch, Allan B. 346
Hatley, Russell Eric (Resident) 150
Hatley, Tina Whytsell (Resident) 300
Haynes, Katherine Anne (Student) 252
Healy, Richard Oliver 596
Heise, Brian Allan (Resident) 596
Helsel, Jay Christopher (Resident) 300
Hendrix, Barry D. (Resident) 300
Henriksen, John Eric (Student) 347
Henry, Mary J. (Resident) 347
Henry, William Bradley 200
Henry, William Warren Jr. 149
Hernandez, Joseph M. (Resident) 300
Hernandez, Nicole B. (Resident) 300
Herrold, Jeffrey William 149
Hester, Wes Lee (Resident) 347
Hill, Chad (Resident) 252
Hill, Harold Randall 200
Hillis, Thomas Michael (Student) 202
Hinton, Thomas Wade (Student) 202
Hodges, Michael Eugene (Resident) 100
Hogan, Scott Matthew (Resident) 100
Hogan, William McCall Jr. (Student) 202
Holland, Cheryl Ann (Student) 202
Holt, Brent Edward (Student) 252
Houston, Melinda Lee (Resident) 54
Howe, Wilson H. (Student) 150
Hudson, Amy Rapp (Resident) 300
Huey, Sandra Sheiron (Resident) 201
Hughes, Alan Wayne 149
Hughes, Juan M. 299
Hutcheson, James Arthur (Resident) 596
-I-
Iqbal, Imran (Resident) 100
Isely, William A. 200
Itzig, Charles Blum, Jr. 252
-J-
Jackson, Edward Leslie (Student) 301
Jackson, Hugh H. (Resident) 100
Jaffar, Muhammad 251
Jarvis, Robert Meacham (Student) 301
Jennings, Bryan Thomas (Student) 301
Jetton, Christina Ann (Resident) 54
Jewell, Shannon A. (Resident) 100
Johnson, Brad D. (Resident) 100
Johnson, Clifton 200
Johnson, David Glenn (Student) 202
Johnson, Larry Austin, Jr. (Student) 301
Jones, Thomas E.B. 149
Jussa, Murad M. (Resident) 150
-K-
Kaemmerling, Kristin Diane (Student) 347
Katz, Catherine A. 99
Katz, Stephen Jerome 201
Kazakevicius, Rimantas (Resident) 596
Keller, David Edward (Student) 252
Kelly, James Edward, III, 299
Keplinger, Florian S. 149
Kidd, Joseph Neil (Resident) 150
Kidd, Tracy Lyon (Resident) 201
King, David L. (Resident) 100
King, William Ronald 299
Kiser, Thomas Scott (Resident) 300
Klutts, James Stacey (Student) 252
Knowles, Glen Carter 200
Knox, Micheal (Student) 202
Kohli Manish (Resident) 300
Koury, Jadd Wadi (Student) 202
Krepps, Angela Swain (Student) 150
Krepps, Brett Thomas (Student) 150
Kueter, Daniel Baltz (Student) 301
-L-
Labor, Penny Megison 200
Labor, Phillips Kirk 99
LaCroix, Michelle Lynn (Student) 347
Lam, Khim Kirsten (Student) 252
Lamb, Johnny M. 346
Lamb, Trent Robert (Resident) 458
Landis, Mark A. 54
Lansford, Bryan Keith 149
Lassieur, Susanne Marie (Student) 301
Lawrence, George Stephen (Student) 301
Lawson, Yolanda R. (Student) 301
LeDay, Romona (Student) 301
Ledbetter, Johnny Roger Jr. (Resident) 201
Levernier, James Edwin 150
Volume 93, Number 12 - May 1997
609
Lewis, Barrett Dean (Student) 202
Lewis, Bruce W. (Student) 347
Linsky, Russell Allen (Student) 252
Logsdon, Todd William (Student) 301
Lowery, Lisa Ann (Resident) 54
Lowery, Ronald L. 299
Lu, Ellen (Student) 252
Lucas, Shauna Lee (Resident) 54
-M-
Mallory, Michael D. (Resident) 300
Malone, Mark Steven (Resident) 201
Marchese, Sandra Marie (Resident) 100
Markham, Larry Wayne (Resident) 150
Marks, Sonya Denise (Student) 301
Marlin, April Renee (Student) 301
Marshall, Marilyn Dianne (Resident) 201
Martin, Joan Barbara 99
Martine, Andrew Ryan (Student) 252
Maxwell, Teresa Marnette 418
McCallum, Sanford B. (Student) 202
McClurkan, Michael Bruce 458
McCourtney, Bill R. II (Student) 252
McGowan, Patrick Francis 346
McGraham, Bethany A. 299
McKelvey, Kent D. (Resident) 54
McLeod, Michael Reilly (Resident) 201
McMahan, Steven Howard (Resident) 100
McMicheal, Wanda V. 200
McNiece, Karen Leslie (Student) 202
Meadors, John N. 149
Meads, Anthony (Student) 301
Melton, Charles Lewis 99
Mendelson, Jeri Kersten (Student) 347
Merchant, Rhonda J. (Resident) 54
Meredith, Paul Drew 54
Miller, Mark E. 150
Mohan, Kumaran K. (Resident) 201
Mohyuddin, Adil Ibrahim 99
Moix, Frank Martin Jr. (Resident) 150
Molette, Sekou F.M. (Resident) 347
Molnar, Istvan 299
Montgomery, Lori E. 418
Moore, Jesse Daniel 200
Moore, John H. 200
Moss, Mark Edward (Student) 150
Mullens, Mark Lee 201
Murillo-Lopez Fernando H. 99
Murray-Stephens, Andrea Jeanette 346
Murry, William Lee 418
Myers, Janette Elaine (Student) 202
-N-
Napolitano, Charles Augustine 346
Nehus, Ezechiel Raymond (Student) 202
Netterville, J. Kevin (Resident) 300
Newcity, Marshall James (Student) 202
Newland, Katherine Diane (Student) 301
Newman, Adam Garrett (Student) 301
Nichol, Brian T. 418
Nguyen, Larry Luong (Resident) 100
Nix, John Edward 251
Norcross, Jonathan Gardner (Student) 202
Norris, Brian Blake (Student) 252
Norsworthy, Twyla Rose (Student) 150
-o-
Oberste, David Jason (Student) 202
O'Donald, Jacqueline Sherrill (Student) 596
Osborne, Rebecca Lynn (Student) 252
O'Sullivan, Patrick J. 300
Over, Darrell Ray (Resident) 201
Owens, Ronald Brian (Student) 347
Ozment, Dennis Wayne (Student) 347
-P-
Pafford, Michael B. (Student) 202
Parchman, Anna Janette (Resident) 418
Parcon, Paul Jeffrey (Resident) 201
Park, Jong Chan (Student) 202
Parker, Arthur Wade 418
Parker, Jason Darrel (Student) 202
Paslidis, Nick John 149
Pastor, Randy Joseph 299
Patel, Ajay S. (Student) 301
Patel, Dharmendra V. 251
Patrick, Donald Lee 458
Patrick, Larry L. 458
Payne, Cheryl L. 150
Peebles, Jody Warren (Student) 301
Petty, Corwin Durant (Student) 301
Phillips, John David (Resident) 300
Phillips, Kristina Michele (Student) 202
Pilkington, Neylon S. 299
Pillow, Gill Gibson (Student) 252
Pillow, James Hargraves (Student) 252
Pinchback, Michael Ellis (Student) 202
Ploetz, Carina 346
Pohle, Floyd G. 300
Price, Angela Michelle (Student) 252
Priest, Dean B., Jr. (Student) 301
Pryor, Shapard Hanner, Jr. 200
Purvis, Kenneth W. 596
-Q-
Quintero, Mauricio (Resident) 300
-R-
Rankin, Jay K. (Resident) 347
Rayford, Richard (Resident) 347
Reid, Graham M. 251
Reynolds, Tara Patrice (Student) 252
Rhodes, Ramona L. (Student) 150
Richey, Jason Dean (Resident) 150
Roach, Milton Carey III (Resident) 150
Roberts, Kimberly Anne (Student) 301
Roberts, Rusty Lynn Jr. (Student) 252
Rodgers, Michelle Leigh (Student) 150
Rodriguez, Paul Lopez 418
Rohde, Melinda S. (Resident) 596
Roper, Richard Kyle 458
Ross, Ashley Sloan III (Student) 202
Ross, Douglas Bryan (Student) 202
Rucker, Gari Mills 149
610
JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Ruddell, Deanna N. 251
Runion, Lance Keith (Resident) 150
Russell, Anthony E. 150
Russell, Shelley White (Resident) 54
-s-
Sadler, Philip K. (Student) 252
Saitta, Michael R. 251
Sambasivan, Arathi (Resident) 300
Sanders, Kelli Keene 251
Sangster, Michael Gerard 201
Sangster, William McCoy 596
Sarna, Paul Duane 201
Sauer, Kenneth Morgan (Student) 202
Schach, Christopher Patrick (Student) 301
Schluterman, Keith Oliver (Student) 202
Schmidt, Richard D. (Student) 347
Schneider, Daniel L. (Student) 301
Schonefeld, Michael D. 596
Schrader, Nancy Lynn 458
Schultz, Charles Edward (Resident) 458
Scruggs, Jennifer Trew (Student) 347
Sheng, Kai (Student) 252
Shenker, David Neal (Student) 596
Shermer, Susanna E. (Student) 252
Sherwood, Chad Leon (Student) 252
Shields, Eddie Wayne 201
Shihabuddin, Bashir Sami (Resident) 347
Shoppach, Jon Paul (Resident) 54
Simpson, Brian Rush (Student) 252
Simpson, Christopher (Student) 301
Sims, LaRhonda Kay (Student)lOO
Singh, Malwinder (Resident) 300
Skinner, Jason Ray (Student) 150
Slack, Tobin Alexander (Resident) 100
Slay, David R. (Resident) 54
Smith, Caroline Clements (Student) 202
Smith, Christopher Todd 150
Smith, Daniel Fuller (Resident) 150
Smith, David Lucas (Student) 202
Smith, James H. (Student) 301
Smith, Matthew W (Resident) 150
Smith-Foley, Stacy Anne (Student) 301
Sorenson, Marney Keith 418
Sorrels, Christopher William (Student) 252
Spann, Aaron Michael (Student) 252
Spiers, Jon Phillip 299
St. Amour, Scott C. 418
St. John, Melody Dawn 299
Stark, James Edgar 251
Stennett, Melissa Diane (Student) 301
Stewart, Casey D. (Resident) 300
Stewart, Jason Garner (Resident) 54
Stewart, R. Todd (Resident) 100
Storey, Mark R. (Resident) 100
Storm, Elizabeth Anne (Student) 202
Suguitan, Demetrio Banaglorioso, Jr. 346
Sutterfield, Vikki Leigh (Resident) 150
Swihart, Camille Hall (Student) 347
-T-
Tagupa, Eumar T.
Volume 93, Number 12 - May 1997
Tatum, Robert Erwin (Resident) 458
Tejada, Ruben 596
Templeton, Gary L. 200
Tharp, Paul S. (Resident) 54
Thomas, Lynn C. (Resident) 202
Thrasher, James Randall (Resident) 54
Tran, Viet N. (Resident) 300
Travis, Patrick M. 251
Tygart, Bryan Phillip (Student) 458
-V-
Valley, Marc A. 150
Van Noy, Joanna W. 150
VanHook, Robert Thomas (Student) 202
Varela, Charles D. 99
Vasudevan, Padmini 54
Verser, Michael Watson 150
Vest, Carl Ernest (Resident) 100
Vogel, Eric David 346
Vorhease, James W. 418
-w-
Wade, James Edward (Student) 202
Wagner, Barbara R. (Resident) 150
Walker, Randy Dean (Student) 150
Ward-Jones, Susan Elizabeth 596
Warner, Justin Don (Student) 252
Waters, Samuel Gregory 200
Webber, John Charles (Resident) 54
West, Boyce W. 458
West, Brian James (Student) 202
West, Margaret Anne (Student) 150
White, Aaron Eugene (Student) 252
White, John S. 596
Whiteside, Thomas Fletcher (Resident) 54
Wiggins, Michael N. (Student) 458
Wilkin, Tim T. (Resident) 202
Wilkins, Benjaman Travis (Student) 301
Willhite, Andrea Kay (Resident) 202
Williams, Mark Courtney (Student) 252
Williams, Nancy Kay (Resident) 202
Williams, W. Frank (Student) 252
Wilson, Kelli Ruth (Student) 458
Wilson, Robert B., Ill, (Student) 301
Winfrey, Cheryl D. 596
Winkler, Jerry Mitchell (Student) 301
Woods, Barbara G. (Student) 150
Woods, Jennifer Leigh (Student) 202
Woods, William K. 418
Woodson, Alexa 149
Wooten, R. Gregory (Resident) 202
Wren, Mark A. 99
Wright, Lonnie Benton (Student) 252
-Y-
Yamada, Ronald Ryo 418
Yeh, Y. Albert (Resident) 300
Young, Matthew Stephen (Resident) 458
Yunus, Nauman 418
-z-
Zangari, Maurizio 54
Zelk, Misty Michelle (Resident) 54
611
Advertisers Index
Advertising Agencies in italics
AMS Benefits inside front
Freemyer Collection System 580
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McNabb, Kelley & Barre
Medical Practice Consultants, Inc 588
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Benson/Smith Advertising
Snell Prosthetic & Orthotic Laboratory back cover
Strategic Marketing
State Volunteer Mutual Insurance Company 574
The Maryland Group
Southwest Capital Management inside back
Marion Kahn Communications, Inc.
U.S. Air Force 573
BJK&E Specialized Advertising
Information for Authors
Original manuscripts are accepted for consideration
on the condition that they are contributed solely to this
journal. Material appearing in The Journal of the Arkansas
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The Journal of the Arkansas Medical Society reserves the
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